Radical Radiation Therapy After Lung-Sparing Surgery for Malignant Pleural Mesothelioma: Survival, Pattern of Failure, and Prognostic Factors.
OBJECTIVE
To prospectively assess the survival, patterns of failure, and prognostic factors in a large cohort of patients with malignant pleural mesothelioma who had undergone a novel trimodal therapeutic approach, including lung-sparing surgery, chemotherapy, and subsequent treatment with high doses of intensity modulated radiation therapy (IMRT) to the whole hemithorax.


METHODS
The analysis was conducted on the data from 69 patients. Of the 69 patients, 35 underwent extended pleurectomy/decortication (P/D), with resection of the entire pleura, along with portions of the pericardium and diaphragm and 34, partial pleurectomy, defined as partial removal of parietal or visceral pleura for diagnostic purposes, leaving gross tumor behind in all cases. All patients received cisplatin/pemetrexed chemotherapy. Postoperative IMRT was delivered to the entire hemithorax, excluding the intact lung. The IMRT dose was 50 Gy in 25 fractions. Any fluorodeoxyglucose-avid areas or regions of particular concern for residual disease were given a simultaneous boost to 60 Gy.


RESULTS
The median follow-up duration was 19 months. No difference was seen in overall survival and locoregional control between the extended P/D group and the partial pleurectomy group. The 2-year overall survival was 65% and 58% in the extended P/D and partial pleurectomy groups, respectively (P=.94). Locoregional control at 2 years was 65% and 64% in the extended P/D and partial pleurectomy groups, respectively (P=.75). The predominant pattern of failure was distant: 19 patients (27.5%) developed distant metastases as the first site of relapse. Gross residual disease after surgery was significantly associated with overall survival (hazard ratio 3.45). One fatal pneumonitis was reported; 14 cases (20%) of grade 2 to 3 pneumonitis were documented.


CONCLUSIONS
Radical IMRT after lung-sparing surgery and chemotherapy for malignant pleural mesothelioma leads to promising survival results and acceptable toxicity rates. The similarity of survival between patients treated with extended P/D or partial pleurectomy observed in our study is intriguing.
Department of Radiation Oncology, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Emilio
E
Minatel
Department of Radiation Oncology, Centro di Riferimento Oncologico of Aviano, Aviano, Italy. Electronic address: marcotrovo33@hotmail.com.
Marco
M
Trovo
Department of Medical Oncology, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Alessandra
A
Bearz
Unit of Epidemiology and Biostatistics, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Matteo
M
Di Maso
Department of Nuclear Medicine, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Tania
T
Baresic
Department of Medical Physics, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Annalisa
A
Drigo
Department of Medical Physics, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Loredana
L
Barresi
Department of Radiation Oncology, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Carlo
C
Furlan
Department of Medical Oncology, Pordenone General Hospital, Pordenone, Italy.
Alessandro
A
Del Conte
Department of Pneumology, Pordenone General Hospital, Pordenone, Italy.
Gioia
G
Bruschi
Department of Thoracic Surgery, Mestre General Hospital, Mestre, Italy.
Paolo
P
Fontana
Department of Surgery, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Vittore
V
Pagan
Department of Radiation Oncology, Centro di Riferimento Oncologico of Aviano, Aviano, Italy.
Giovanni
G
Franchin
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D002945:Cisplatin / Q000008:administration & dosage; D015331:Cohort Studies; D003131:Combined Modality Therapy / Q000379:methods; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D008168:Lung; D008175:Lung Neoplasms / Q000401:mortality / Q000532:radiotherapy* / Q000556:secondary / Q000628:therapy; D008297:Male; D008654:Mesothelioma / Q000401:mortality / Q000532:radiotherapy* / Q000556:secondary / Q000628:therapy; D000086002:Mesothelioma, Malignant; D008875:Middle Aged; D018365:Neoplasm, Residual; D059351:Organ Sparing Treatments; D000068437:Pemetrexed / Q000008:administration & dosage; D010994:Pleura / Q000601:surgery; D010997:Pleural Neoplasms / Q000401:mortality / Q000532:radiotherapy* / Q000628:therapy; D011446:Prospective Studies; D050397:Radiotherapy, Intensity-Modulated; D016019:Survival Analysis; D016896:Treatment Outcome
D000970:Antineoplastic Agents; D000068437:Pemetrexed; D002945:Cisplatin