Received: 14 December 2016 Accepted: 2 February 2017 Published on: 29 March 2017
Intensity modulated radiation therapy after extra-pleural
pneumonectomy for malignant pleural mesothelioma
is feasible without fatal pulmonary toxicity and provides good
Department of Radiation Oncology, Baylor
Scott and White Health, Temple, Texas, USA
Biostatistics, Baylor Scott and White Health,
Temple, Texas, USA
Hematology and Oncology, Baylor Scott and
White Health, Temple, Texas, USA
Radiation Oncology, Austin Cancer Centers,
Sameer Jhavar, Department of Radiation Oncol-
ogy, Baylor Scott and White Health, 2401 South
31st Street, Temple, Texas 76508.
Work performed at Baylor Scott and White
Health: 2401 S. 31st Street, Temple, Texas
Aim: To analyze patterns of failure, toxicity, relapse-free survival (RFS), and overall survival (OS) in
malignant pleural mesothelioma (MPM) patients treated with intensity-modulated radiation ther-
apy following extrapleural pneumonectomy (EPP).
Methods: We reviewed 18 charts of patients with MPM from 2005 to 2014 who underwent EPP
followed by hemithoracic intensity-modulated radiation therapy. Intensity-modulated radiation
therapy dose delivery adhered to published lung dose constraints. Kaplan-Meier curves were used
to assess the RFS and OS. Median survival times are reported for both RFS and OS.
Results: Median age was 65 years (range: 40—76 years). Chemotherapy was administered in four
neo-adjuvant and seven adjuvant patients. Pathological American Joint Committee on Cancer
stages II, III, IV, surgical margin, lympho-vascular space, pericardium, and chest wall involvement
were seen in 3, 12, 3, 9, 7, 12 and 3 patients, respectively. The majority of the patients received
45 Gy in 25 fractions. The mean lung dose was 7.14 Gy (range: 5 Gy–9.3 Gy). The mean V20 was
2.23%. At a median follow-up of 3 years, eight patients were alive (44%); 10 experienced relapse
(56%). Median RFS and OS were 24.4 months (95% CI: >16.3 months) and 38.2 months (95%
CI: 17.4–78.1 months), respectively. Acute toxicities were fatigue, dermatitis, nausea, esophagi-
tis/dysphagia, cough, and dyspnea on exertion. No grade III, IV, or fatal pulmonary toxicities were
Conclusion: Intensity-modulated radiation therapy following EPP for MPM resulted in RFS and
OS comparable to the published literature without signiﬁcant toxicity.
extra pleural pnemonectomy, intensity modulated radiation therapy, malignant pleural
Malignant pleural mesothelioma (MPM) is a rare but deadly malignant
neoplasm arising in the pleura with approximately 2500 cases diag-
nosed annually in the United States and a median survival of 12 months
(median survival in most series is 4–20 months).
remains the greatest risk factor with 70–80% of MPM patients having
documented exposure to asbestos: men are more commonly affected
The management of MPM is challenging and controversial.
Broadly, there is debate regarding the optimal surgical approach of
extrapleural pneumonectomy (EPP) versus lung sparing approaches,
such as pleurectomy and decortication (P/D).
regardless of the surgical approach, relapse is common after
surgery and is predominantly loco-regional with subsequent dis-
Aggressive local therapy with surgery followed by
adjuvant radiation plays a major role in the multimodal management
to improve local control.
2017 John Wiley & Sons Australia, Ltd Asia-Pac J Clin Oncol. 2018;14:e88–e94.wileyonlinelibrary.com/journal/ajco