Patterns of Failure, Toxicity, and Survival after Extrapleural Pneumonectomy and Hemithoracic Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma

Abstract

Introduction We investigated safety, efficacy, and recurrence after postoperative hemithoracic intensity-modulated radiation therapy (IMRT) in patients with malignant pleural mesothelioma (MPM)treated with extrapleural pneumonectomy (EPP) during the past decade at a single institution. Methods In 2001–2011, 136 consecutive patients with MPM 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 v4.0; survival outcomes were estimated with the Kaplan-Meier method; and local-regional 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 was 14.7 months. Rates of grade ≥ 3 toxicity were skin 17%, lung 12%, heart 2.3%, and gastrointestinal toxicity 16%. Five patients experienced grade 5 pulmonary toxicity. Rates of local-regional recurrence-free survival, distant metastasis-free survival (DMFS), 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 (FEV1), non-epithelioid histology, and nodal status were associated with DMFS and OS. Conclusion IMRT after EPP is associated with low rates of local-regional recurrence, though some patients experience life-threatening lung toxicity. Tumor histology and nodal status can be helpful for identifying patients for this aggressive treatment.

Relapse pattern and second-line treatment following multimodality treatment for malignant pleural mesothelioma

“…Improved local control after hemithoracic radiotherapy has been described earlier [10,15]. In our cohort, 59 patients (56%) received adjuvant radiation and the incidence of local tumour recurrence was reduced significantly but without significant influence on OS, which is in line with results from our multicenter randomized controlled trial (MC RCT) of the SAKK 17/04 protocol [13].…”

Hemithoracic Intensity Modulated Radiation Therapy After Pleurectomy/Decortication for Malignant Pleural Mesothelioma: Toxicity, Patterns of Failure, and a Matched Survival Analysis

“…Additional information on surgical procedures, radiation therapy techniques, and methods of data collection for the matched cohort of patients treated with EPP has been reported elsewhere (4). Treatment toxicity, overall survival (OS), progression-free survival (PFS), time to LRF (tLRF), and time to DM (tDM) in patients treated with PD-IMRT were then compared with the matched cohort of patients treated with EPP-IMRT.…”

“…Extrapleural pneumonectomy (EPP) with en bloc resection of the pleura, lung, ipsilateral diaphragm, and pericardium is a high-risk surgery that provides good local control when combined with adjuvant radiation therapy (2)(3)(4). However, recent studies have shown increased morbidity with similar overall survival for EPP versus lung-sparing techniques, despite local recurrence rates between 60% and 100% with lung-sparing surgery alone (5)(6)(7).…”

Malignant pleural mesothelioma: adjuvant therapy with radiation therapy

“…Anderson Cancer Center (MDACC) has one of the largest experiences in the use of IMRT after pneumonectomy (12). A retrospective analysis of 86 patients who underwent IMRT after surgery was reported.…”