The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation

Abstract

Introduction: Detailed guidelines regarding the use of radiation therapy for malignant pleural mesothelioma (MPM) are currently lacking because of the rarity of the disease, the wide spectrum of clinical presentations, and the paucity of high-level data on individual treatment approaches.

Role of radiation treatment in multimodality treatment of malignant pleural mesothelioma: a narrative review

“…The results from this trial aligned those from a meta-analysis of five randomized controlled trials, which concluded that prophylactic radiotherapy did not reduce procedure site recurrence (29). Consensus recommendations from a multidisciplinary team of mesothelioma expects do not recommend radiation to prevent PTMs, with the exception of patients with histologically confirmed positive procedure tracts (18). More research is warranted on specifically for the population with epithelioid tumors to determine if there is any benefit.…”

“…Progression-free survival remained low largely due to a high distant relapse rate of 81%, with the majority of this being outside the radiotherapy field. Additionally, while authors concluded that results did not support the routine use of radiation therapy after EPP, the trial had several limitations including lack of statistical power, and experts have continued to recommend radiation therapy in conjunction with EPP despite the results of this trial (18). Table 1 summarizes the above studies and reported median overall survival for patients undergoing EPP and subsequent radiotherapy.…”

“…While RHR is promising for increased survival of patients with MPM who receive lung-sparing surgery, patients must be carefully selected given the non-negligible side effects of increased radiation doses. A consensus expert opinion from the National Cancer Institute, International Association for the Study of Lung Cancer Research, and Mesothelioma Applied Research Foundation recommends, based on the current literature, that in patients with two intact lungs, the mean lung dose should be kept to 20.5 Gy or less, the total lung V 20 (volume receiving 20 Gy or more) to 37% or less, the ipsilateral lung V 40 (volume receiving 40 Gy or more) to 67% or less, and the contralateral lung dose to <8 Gy (18). Clinical practice guidelines from the American Society of Clinical Oncology recommend that IMRT following lung-sparing surgery should be performed only at highly experienced centers, preferably in the context of a clinical trial, given the toxicity concerns (27).…”

The “Radical” Palliation That Increases Survival in Malignant Pleural Mesothelioma

“…To the Editor: Much-needed consensus recommendations on the use of radiation therapy for malignant pleural mesothelioma (MPM) were recently provided by an expert panel. 1 The authors focused their efforts to standardize/optimize radical treatments, with adjuvant radiotherapy delivered before or after extrapleural pneumonectomy or after pleurectomy/decortication. However, new studies are opening the way to reconsider a more aggressive approach in the palliative setting in view of preliminary evidence on increasing patients' overall survival.…”

Response to Letter to Editor from Fodor et al., “The ‘Radical' Palliation That Increases Survival in Malignant Pleural Mesothelioma”

“…We thank Fodor et al 1 for their thoughtful letter pertaining to our recent expert opinion paper on radiation therapy in the treatment of malignant pleural mesothelioma (MPM). 2 We are also aware of the promising results of the phase III randomized trial by Minatel et al, 3 suggesting that although follow-up is limited, a more aggressive radical hemithoracic radiotherapy (RHR) approach with a simultaneous integrated boost (SIB) may improve survival outcomes compared with palliative radiation therapy to a limited treatment area. Toxicity rates in the RHR group were also notable, with approximately 10% of patients experiencing grade 3 or higher pneumonitis and another 10% experiencing grade 4 late respiratory failure requiring oxygen.…”