Long-term outcomes of intensity-modulated radiotherapy following extra-pleural pneumonectomy for malignant pleural mesothelioma

Figures & data

Table 1. Pre-determined constraints on dose-volume parameters for organs at risk and those from treatment plans.

Organs at risk	Constraints		Actual plan, Median (range)		Compliance rate
Lung- contra	V5	<55%	44.9	(25.3–60.9)	95.2%
	V20	<8%	5.0	(1.7–15.9)	76.2%
	MLD	<8 Gy	6.8	(4.9–10.7)	81.0%
Liver	V30	<55%	42.8	(1.7–69.9)	81.0%
Kidney- contra	V23	= 0%	0.0	(0.0–5.6)	90.5%
Kidney- ipsi	V23	<60%	58.2	(31.6–95.2)	57.1%
Heart	V40	<30%	41.2	(13.9–92.7)	23.8%
	Dmax	<60 Gy	56.6	(44.4–60.7)	90.5%
Spinal cord	Dmax	<50 Gy	46.4	(38.5–48.8)	100%

contra: contralateral; ipsi: ipsilateral; MLD: mean lung dose; Dmax: maximal dose; Vx: relative volume receiving x Gy or more.

Table 2. Patient characteristics.

Sex	male:female	19:2
Age (y)	median (range)	61 (48–73)
Histology	epithelioid: sarcomatoid: biphasic	17: 2: 2
Side	right: left	15: 6
p-Stage	I: II: III: IV	0: 4: 16: 1
	T1: T2: T3: T4	0: 5: 15: 1
	N0: N1: N2	9: 1: 11
Chemotherapy	pre-operative: post-operative	5: 16
	CDDP/GEM: CDDP/PEM	1: 20

CDDP: cisplatin; GEM: gemcitabine; PEM: pemetrexed.

Figure 1. Dose distribution in a patient who developed severe cardiac toxicity. Maximal dose, mean dose and V40 of the heart were 57.0 Gy, 41.0 Gy and 60.7%, respectively.

Table 3. Acute and late toxicities grade 2 or worse.

	G2	G3	G4
Acute (n = 21)
Hematologic
Anemia	5	3
Leukocytopenia	7	2
Thrombocytopenia	1	3	6
Non-hematologic
Nausea/vomiting	6	4
Fatigue	6	2
Pneumonitis	1	3
Esophagitis	7	1
Dermatitis	4
Late (n = 18)
Hematologic
Anemia	1
Thrombocytopenia			1
Non-hematologic
Transaminase	1	1
Biliary enzyme	2	3
Creatinine	1
Fatigue	1
Chest wall pain	1
Cardiogenic brain embolism			1

Figure 2. Overall survival since intensity-modulated radiotherapy (IMRT).

Figure 3. Overall survival according to N-stage.

Table 4. Selected series of IMRT following EPP.

		Prescribed dose		Side	Histology	N-stage		Toxicities
Author (year)	N	Hemithorax	Boost	(R/L)	(Epi/Others)	(N0–1/2–3)	Local recurrence	Lung Gr 3+	Any Gr 5
Sylvestre (2011) [12]	24^a	50 Gy	57.2 Gy	7/17	19/5	21/8	2 (8%)	4 (17%)	2 (8.3%)
Tonoli (2011) [13]	56^b	50 Gy	60 Gy	32/24	54/2	44/12	5 (9%)	(2.2%)	2 (3.6%)
Patel (2012) [14]	30	45 Gy	56.8 Gy	15/15	22/8	23/7	10 (33%)	4 (13%)	1 (3.3%)
Gomez (2013) [15]	86	45–50 Gy	55–60 Gy	57/29	66/23	59/27	14 (16%)	10 (12%)	5 (5.8%)
Kimura (2015) [16]	15	54 Gy	61.6 Gy	8/7	10/5	12/3	5 (33%)	3 (20%)	0 (0%)
Thieke (2015) [17]	62	48–54 Gy	none	35/27	44/18	49/13	(60%@3y)	1 (1.6%)	0 (0%)
Present study	21	50.4 Gy	56 Gy, 61.6 Gy	15/6	17/4	10/11	2 (10%)	3 (14%)	0 (0%)

IMRT: intensity-modulated radiotherapy; EPP: extra-pleural pneumonectomy; N: number of patients; Epi: epithelioid; OS: overall survival; Gr: grade.

^a Including one patient who underwent non-EPP surgery.

^b Including four patients treated with non-IMRT radiotherapy.

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