title: Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77054, USA. dgomez@mdanderson.org
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Gomez
authors.forename: David S
authors.initials: DS
authors.lastname: Hong
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Allen
authors.forename: James S
authors.initials: JS
authors.lastname: Welsh
authors.forename: Reza J
authors.initials: RJ
authors.lastname: Mehran
authors.forename: Anne S
authors.initials: AS
authors.lastname: Tsao
authors.forename: Zhongxing
authors.initials: Z
authors.lastname: Liao
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Bilton
authors.forename: Ritsuko
authors.initials: R
authors.lastname: Komaki
authors.forename: David C
authors.initials: DC
authors.lastname: Rice
mesh_terms: D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008654:Mesothelioma / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D009367:Neoplasm Staging; D010997:Pleural Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D011013:Pneumonectomy / Q000009:adverse effects / Q000401:mortality*; D011183:Postoperative Complications; D011832:Radiation Injuries / Q000209:etiology*; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000401:mortality*; D012189:Retrospective Studies; D015996:Survival Rate; D017211:Treatment Failure