Disease-Related Outcomes and Toxicities of Intensity-Modulated Radiation Therapy Following Lung-Sparing Pleurectomy for Malignant Pleural Mesothelioma: A Systematic Review.

Practical Radiation Oncology 2020 February 20 [Link]

Patel R, Ludmir EB, Miccio JA, Menon H, Barsky AR, Mesko SM, Kodali M, Lautenschlaeger T, Adeberg S, Simone CB 2nd, Verma V



To explore the use of intensity-modulated radiotherapy (IMRT) after lung-sparing surgery in malignant pleural mesothelioma (MPM). Because severe toxicities have been documented following radiotherapy for MPM, its use remains controversial, especially as modern surgical management has shifted towards lung-sparing extended pleurectomy/decortication (eP/D). IMRT is an advanced technique that may allow for safer radiotherapy delivery, but there remains limited data (including no summative data) to support this notion.


We performed the first systematic review evaluating the safety and efficacy of post-pleurectomy IMRT (P-IMRT). A systematic review of PubMed using PRISMA guidelines was conducted for publications of all dates that specifically reported clinical outcomes and/or toxicities of P-IMRT in patients with MPM. Ten original studies were included in this review.


Incidence of grade 3 pneumonitis ranged from 0-16%, with all but two studies reporting rates below 9%. Grade 4 and 5 pneumonitis were observed in less than 1.5% of cases, except in one publication that utilized hypofractionated radiotherapy to doses >60 Gy. Crude local failure rates ranged from 19-60%, median progression free survival ranged from 12-16 months, and median overall survival ranged from 19-28 months.


P-IMRT produces relatively few higher-grade toxicities, and has reasonable disease-related outcomes, especially when delivering using conventionally-fractionated regimens to doses of 45-54 Gy and exercising careful attention to dose constraints during treatment planning. IMRT can thus be considered in well-selected patients in whom adequate survival following pleurectomy is expected. These data also support the initiation of the phase III NRG-LU006 trial of eP/D and chemotherapy with or without IMRT.