title: Failure patterns after hemithoracic pleural intensity modulated radiation therapy for malignant pleural mesothelioma.
abstract: OBJECTIVE
  We previously reported our technique for delivering intensity modulated radiation therapy (IMRT) to the entire pleura while attempting to spare the lung in patients with malignant pleural mesothelioma (MPM). Herein, we report a detailed pattern-of-failure analysis in patients with MPM who were unresectable or underwent pleurectomy/decortication (P/D), uniformly treated with hemithoracic pleural IMRT.
  
  
  METHODS
  Sixty-seven patients with MPM were treated with definitive or adjuvant hemithoracic pleural IMRT between November 2004 and May 2013. Pretreatment imaging, treatment plans, and posttreatment imaging were retrospectively reviewed to determine failure location(s). Failures were categorized as in-field (within the 90% isodose line), marginal (<90% and ≥50% isodose lines), out-of-field (outside the 50% isodose line), or distant.
  
  
  RESULTS
  The median follow-up was 24 months from diagnosis and the median time to in-field local failure from the end of RT was 10 months. Forty-three in-field local failures (64%) were found with a 1- and 2-year actuarial failure rate of 56% and 74%, respectively. For patients who underwent P/D versus those who received a partial pleurectomy or were deemed unresectable, the median time to in-field local failure was 14 months versus 6 months, respectively, with 1- and 2-year actuarial in-field local failure rates of 43% and 60% versus 66% and 83%, respectively (P=.03). There were 13 marginal failures (19%). Five of the marginal failures (38%) were located within the costomediastinal recess. Marginal failures decreased with increasing institutional experience (P=.04). Twenty-five patients (37%) had out-of-field failures. Distant failures occurred in 32 patients (48%).
  
  
  CONCLUSIONS
  After hemithoracic pleural IMRT, local failure remains the dominant form of failure pattern. Patients treated with adjuvant hemithoracic pleural IMRT after P/D experience a significantly longer time to local and distant failure than patients treated with definitive pleural IMRT. Increasing experience and improvement in target delineation minimize the incidence of avoidable marginal failures.
authors: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York. Electronic address: rimnera@mskcc.org.
authors: Andreas
authors: A
authors: Rimner
authors: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
authors: Daniel E
authors: DE
authors: Spratt
authors: Department of Medicine, Thoracic Oncology Service, Memorial Sloan-Kettering Cancer Center; Weill Cornell Medical College, New York, New York.
authors: Marjorie G
authors: MG
authors: Zauderer
authors: Department of Radiation Oncology, Mount Sinai Medical Center, New York, New York.
authors: Kenneth E
authors: KE
authors: Rosenzweig
authors: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
authors: Abraham J
authors: AJ
authors: Wu
authors: Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
authors: Amanda
authors: A
authors: Foster
authors: Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York.
authors: Ellen D
authors: ED
authors: Yorke
authors: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.
authors: Prasad
authors: P
authors: Adusumilli
authors: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York.
authors: Valerie W
authors: VW
authors: Rusch
authors: Department of Medicine, Thoracic Oncology Service, Memorial Sloan-Kettering Cancer Center; Weill Cornell Medical College, New York, New York.
authors: Lee M
authors: LM
authors: Krug
mesh_terms: D000368:Aged; D003131:Combined Modality Therapy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy* / Q000556:secondary / Q000601:surgery; D008207:Lymphatic Metastasis; D008297:Male; D008654:Mesothelioma / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy* / Q000556:secondary / Q000601:surgery; D000086002:Mesothelioma, Malignant; D008875:Middle Aged; D059351:Organ Sparing Treatments / Q000379:methods; D010994:Pleura / Q000601:surgery; D010997:Pleural Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D011859:Radiography; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D012189:Retrospective Studies; D017211:Treatment Failure