Malignant pleural mesothelioma (MPM) is a rare malignancy with a poor
prognosis. In recent years, significant progress has been made in the
treatment of this disease, including surgical and radiotherapy techniques,
systemic and immunotherapy. Due to the wide range of clinical presentations,
lack of phase III randomized trials, and heterogeneity in treatment
approach, the treatment of malignant pleural mesothelioma remains
challenging regardless of available diagnostic and therapeutic guidelines.
The limited possibility to avoid critical healthy organs (particularly
lungs) which can lead to severe, and even fatal radiation-induced toxicity,
makes high-dose radical radiotherapy very demanding. Thus, the majority of
patients in the era of conventional radiotherapy were mostly referred to no
more than palliative radiotherapy only. Technological development in
radiotherapy such as respiratory gating, 4D computed tomography (4DCT),
intensity-modulated radiotherapy (IMRT), volumetric modulated arc therapy
(VMAT), stereotactic techniques, and proton therapy, made a step forward in
treating malignant pleural mesothelioma with this modality. Today, MPM
radiotherapy can be considered in various indications, alone or in
combination with surgery and systemic treatment. However, many questions
remain open, and further investigation is needed especially in dose
escalation possibility and lung sparing.