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. 2013 Feb;8(2):238-45.
doi: 10.1097/JTO.0b013e31827740f0.

Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma

Daniel R Gomez  1 , David S Hong, Pamela K Allen, James S Welsh, Reza J Mehran, Anne S Tsao, Zhongxing Liao, Stephen D Bilton, Ritsuko Komaki, David C Rice
Affiliations

Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma

Daniel R Gomez et al. J Thorac Oncol. 2013 Feb.

Abstract

Introduction: We investigated safety, efficacy, and recurrence after postoperative hemithoracic intensity-modulated radiation therapy (IMRT) in patients with malignant pleural mesothelioma treated with extrapleural pneumonectomy (EPP), during the past decade at a single institution.

Methods: In 2001-2011, 136 consecutive patients with malignant pleural mesothelioma 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 version 4.0; survival outcomes were estimated with the Kaplan-Meier method; and locoregional 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 receiving IMRT was 14.7 months. Toxicity rates of grade of 3 or more were: skin 17%, lung 12%, heart 2.3%, and gastrointestinal toxicity 16%. Five patients experienced grade 5 pulmonary toxicity. Rates of locoregional recurrence-free survival, distant metastasis-free survival, 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, nonepithelioid histology, and nodal status were associated with distant metastasis-free survival and OS.

Conclusion: IMRT after EPP is associated with low rates of locoregional recurrence, though some patients experience life-threatening lung toxicity. Tumor histology and nodal status can be helpful in identifying patients for this aggressive treatment.

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Figures

FIGURE 1
FIGURE 1
Kaplan-Meier survival curves for patients treated with extrapleural pneumonectomy followed by intensity-modulated radiation therapy for malignant pleural mesothelioma. (A) Local-regional–progression free survival; (B) distant metastasis–free survival; (C) overall survival.
FIGURE 2
FIGURE 2
Fused PET/CT scans and radiation isodose curves (left) and diagnostic PET scans (right) of treatment failures in two different patients after extrapleural pneumonectomy followed by intensity-modulated radiation therapy for malignant pleural mesothelioma. (A) Arrows indicate failure within a “cold spot” where the isodose lines curved inward along the chest wall and thus compromised target coverage in this portion of the radiation field. (B) Recurrence in high-dose region and within subcutaneous tissues adjacent to the surgical scar.
FIGURE 3
FIGURE 3
Comparison of EPP alone with EPP + IMRT with regards to, a) overall survival, and b) disease-free survival.
FIGURE 4
FIGURE 4
Kaplan-Meier curves illustrating (A) distant metastasis and (B) overall survival according to nodal status and histologic subtype in patients treated with extrapleural pneumonectomy plus intensity modulated radiation therapy.
See this image and copyright information in PMC

Comment in

References

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