Accelerated hemithoracic radiation followed by extrapleural pneumonectomy for malignant pleural mesothelioma

J Thorac Cardiovasc Surg. 2016 Feb;151(2):468-73. doi: 10.1016/j.jtcvs.2015.09.129. Epub 2015 Oct 19.


Objective: To evaluate a new protocol of accelerated hemithoracic intensity-modulated radiation therapy (IMRT) followed by extrapleural pneumonectomy (EPP) for patients with resectable malignant pleural mesothelioma (MPM).

Methods: A total of 25 Gy of radiation was delivered in 5 daily fractions over 1 week to the entire ipsilateral hemithorax with concomitant boost of 5 Gy to volumes at high risk based on computed tomography and positron emission tomography scan findings. EPP was performed at 6 ± 2 days after the end of radiation therapy. Adjuvant chemotherapy was offered to patients with ypN2 disease.

Results: A total of 62 patients were included between November 2008 and October 2014. One patient died in the hospital 2 months after EPP, for an operative mortality of 1.6%, and 2 died after discharged from the hospital for an overall treatment-related mortality (grade 5 toxicity) of 4.8%. Twenty-four patients (39%) developed grade 3 to 5 (grade 3+) complications. On final pathology, 94% of the patients were stage III or IV, and 52% had ypN2 disease. The median survival for all patients as an intention-to-treat analysis was 36 months. The median overall survival and disease-free survival was 51 and 47 months, respectively, in epithelial subtypes, compared with 10 and 8 months in biphasic subtypes (P = .001). Ipsilateral chest recurrence occurred in 8 patients.

Conclusions: Accelerated hemithoracic IMRT followed by EPP has become our preferred approach for resectable MPM. The results have been encouraging in patients with epithelial subtype.

Keywords: MPM; mesothelioma; short course radiation; surgery.

Publication types

  • Clinical Trial, Phase II

MeSH terms

  • Chemotherapy, Adjuvant
  • Disease Progression
  • Disease-Free Survival
  • Hospital Mortality
  • Humans
  • Kaplan-Meier Estimate
  • Mesothelioma / mortality
  • Mesothelioma / pathology
  • Mesothelioma / therapy*
  • Neoadjuvant Therapy* / adverse effects
  • Neoadjuvant Therapy* / mortality
  • Neoplasm Recurrence, Local
  • Neoplasm Staging
  • Ontario
  • Pleural Neoplasms / mortality
  • Pleural Neoplasms / pathology
  • Pleural Neoplasms / therapy*
  • Pneumonectomy* / adverse effects
  • Pneumonectomy* / mortality
  • Positron-Emission Tomography
  • Radiation Dosage
  • Radiotherapy, Adjuvant
  • Radiotherapy, Intensity-Modulated* / adverse effects
  • Radiotherapy, Intensity-Modulated* / mortality
  • Risk Factors
  • Time Factors
  • Tomography, X-Ray Computed
  • Treatment Outcome