GOECP/SEOR clinical guidelines on radiotherapy for malignant pleural mesothelioma

Abstract

Malignant pleural mesothelioma (MPM) is a rare tumor with poor prognosis and rising incidence. Palliative care is common in MPM as radical treatment with curative intent is often not possible due to metastasis or extensive locoregional involvement. Numerous therapeutic advances have been made in recent years, including the use of less aggressive surgical techniques associated with lower morbidity and mortality (e.g., pleurectomy/decortication), technological advancements in the field of radiotherapy (intensity-modulated radiotherapy, image-guided radiotherapy, stereotactic body radiotherapy, proton therapy), and developments in systemic therapies (chemotherapy and immunotherapy). These improvements have had as yet only a modest effect on local control and survival. Advances in the management of MPM and standardization of care are hampered by the evidence to date, limited by high heterogeneity among studies and small sample sizes. In this clinical guideline prepared by the oncological group for the study of lung cancer of the Spanish Society of Radiation Oncology, we review clinical, histologic, and therapeutic aspects of MPM, with a particular focus on all aspects relating to radiotherapy, including the current evidence base, associations with chemotherapy and surgery, treatment volumes and planning, technological advances, and reradiation.

Keywords: Chemotherapy; Malignant pleural mesothelioma; Radiation techniques; Radiotherapy; Reradiation; Surgery.

Figure 1

Clinical target volume: Volume encompassing entire pleura and ipsilateral chest wall as well as any sites at risk of residual disease. A: Chest wall and ribs; B: Lateral border of sternum; C: Costovertebral joints and lateral edge of vertebra; D: Surgical incision area; E: Anterior pericardium.

Figure 2

Volumetric modulated arc therapy with three complete arcs. Isodose: blue (5040 cGy-100%), red (4788 cGy-95%), purple (5292 cGy-105%).

Figure 3

Patient with left malignant pleural mesothelioma treated with volumetric modulated arc therapy with palliative intent.

Figure 4

Patient with predominantly central malignant pleural mesothelioma treated with volumetric modulated arc therapy.

Figure 5

Dose distribution of radiotherapy treatment with volumetric modulated arc therapy. Note the adequate conformation to the clinical treatment volume, avoiding organs at risk.

Figure 6

Low dose distribution of radiotherapy treatment with volumetric modulated arc therapy. Note the adequate conformation to the clinical treatment volume, avoiding organs at risk, specially the heart, esophagus, and contralateral lung.