title: Updated patterns of failure after multimodality therapy for malignant pleural mesothelioma.
abstract: OBJECTIVE
  We have previously described patterns of failure after extrapleural pneumonectomy and multimodality therapy for malignant pleural mesothelioma and sought to update our results with a larger cohort of recent patients.
  
  
  METHODS
  A total of 169 patients underwent extrapleural pneumonectomy without preoperative chemotherapy between 2001 and 2010. Data for treatment, recurrence, and survival were determined from medical records. A thoracic radiologist reviewed postoperative computed tomography or positron emission tomography computed tomography scans to determine sites of recurrence. Time to recurrence was estimated by the Kaplan-Meier method. Rates were compared using the Fisher exact test.
  
  
  RESULTS
  The median age of patients was 62 years. Histology on final pathology was epithelial for 104 patients (62%) and nonepithelial for 65 patients (38%). A total of 132 patients (78%) received heated intraoperative chemotherapy; 77 patients (45%) received adjuvant chemotherapy, and 71 patients (42%) received adjuvant radiation therapy. Most chemotherapy regimens included platinum or pemetrexed. Median radiation therapy dose was 54 Gy. Among 158 evaluable patients, a recurrence developed in 118 (75%). Median follow-up was 83 months, median time to recurrence was 13.1 months, and median survival was 15 months. Sites of first recurrence were in the ipsilateral hemithorax or mediastinum for 54% of patients, in the abdomen for 39% of patients, in the contralateral hemithorax for 28% of patients, and in other distant sites for 5% of patients. Some patients had simultaneous recurrences in multiple sites.
  
  
  CONCLUSIONS
  The most common site of recurrence after extrapleural pneumonectomy and planned multimodality therapy remains the ipsilateral hemithorax (including mediastinum), and true distant failure (other than the abdomen or contralateral hemithorax) remains unusual. The distribution of recurrences is strikingly similar to our prior report.
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Mass. Electronic address: ebaldini@partners.org.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Baldini
authors.affiliation: Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: William G
authors.initials: WG
authors.lastname: Richards
authors.affiliation: Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Ritu R
authors.initials: RR
authors.lastname: Gill
authors.affiliation: Division of Thoracic Surgery, Geisinger Health System, Wilkes-Barre, Pa.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Goodman
authors.affiliation: University of Kentucky College of Medicine, Lexington, Ky.
authors.forename: Olivia K
authors.initials: OK
authors.lastname: Winfrey
authors.affiliation: Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Hannah M
authors.initials: HM
authors.lastname: Eisen
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Mass.
authors.forename: Raymond H
authors.initials: RH
authors.lastname: Mak
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Mass.
authors.forename: Aileen B
authors.initials: AB
authors.lastname: Chen
authors.affiliation: Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, Mass.
authors.forename: David E
authors.initials: DE
authors.lastname: Kozono
authors.affiliation: Division of Thoracic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Raphael
authors.initials: R
authors.lastname: Bueno
authors.affiliation: Division of Thoracic Surgery, Debakey Institute, Houston, Tex.
authors.forename: David J
authors.initials: DJ
authors.lastname: Sugarbaker
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000627:therapeutic use*; D001900:Boston / Q000453:epidemiology; D017024:Chemotherapy, Adjuvant; D018450:Disease Progression; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000401:mortality / Q000556:secondary / Q000628:therapy*; D008297:Male; D008654:Mesothelioma / Q000401:mortality / Q000556:secondary / Q000628:therapy*; D000086002:Mesothelioma, Malignant; D008875:Middle Aged; D064847:Multimodal Imaging; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local; D010997:Pleural Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D011013:Pneumonectomy / Q000009:adverse effects* / Q000401:mortality; D049268:Positron-Emission Tomography; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure