Radical Radiation Therapy after Lung-Sparing Surgery for Malignant Pleural Mesothelioma: Survival, Pattern of Failure, and Prognostic Factors
Menée sur 69 patients atteints d'un mésothéliome pleural malin (durée médiane de suivi : 19 mois), cette étude évalue l'efficacité, du point de vue de la survie, de fortes doses de radiothérapie avec modulation d'intensité après un traitement comportant une intervention chirurgicale préservant le poumon et une chimiothérapie par cisplatine-pémétrexed, puis identifie les formes de récidive et les facteurs pronostiques associés
Purpose/Objective(s) : To prospectively assess survival, pattern of failures and prognostic factors in a large cohort of malignant pleural mesothelioma (MPM) patients who underwent a novel trimodal therapeutic approach, including lung-sparing surgery, chemotherapy and subsequent treatment with high doses of intensity-modulated radiation therapy (IMRT) to the whole hemithorax. Methods and Materials : The analysis was conducted on 69 patients: 35 underwent extended P/D, with the resection of the entire pleura, along with portions of the pericardium and diaphragm; 34 underwent partial pleurectomy, defined as partial removal of parietal or visceral pleura for diagnostic purposes, leaving gross tumor behind in all cases. All patients received cisplatin/pemetrexed chemotherapy. Post-operative IMRT was delivered to the entire hemithorax excluding the intact lung. IMRT dose was 50 Gy in 25 fractions. Any FDG-avid areas or regions of particular concern for residual disease were given a simultaneous boost to 60 Gy. Results : The median follow-up duration was 19 months. There was no difference in overall survival (OS) and loco-regional control (LRC) between extended P/D group and partial pleurectomy group. The 2-year OS was 65% and 58% in extended P/D group and partial pleurectomy group, respectively (p=0.94). LRC at 2 years was 65% and 64% in extended P/D group and partial pleurectomy group (p=0.75). The predominant pattern of failure was distant: 19 (27.5%) patients developed distant metastases as the first site of relapse. Gross residual disease after surgery was significantly associated with OS (hazard ratio = 3.45). One fatal pneumonitis was reported. Fourteen (20%) Grade2-3 pneumonitis were documented. Conclusions : Radical IMRT following lung-sparing surgery and chemotherapy for MPM leads to promising survival results and acceptable toxicity rates. The similarity of survival between patients treated with extended P/D or partial pleurectomy observed in our study is intriguing.
http://www.redjournal.org/article/S0360-3016%2815%2900705-1/abstract