Rice David C, Stevens Craig W, Correa Arlene M, Vaporciyan Ara A, Tsao Anne, Forster Kenneth M, Walsh Garrett L, Swisher Stephen G, Hofstetter Wayne L, Mehran Reza J, Roth Jack A, Liao Zhongxing, Smythe W Roy
Department of Thoracic and Cardiovascular Surgery, University of Texas, MD Anderson Cancer Center, Houston, Texas 77030, USA.
Ann Thorac Surg. 2007 Nov;84(5):1685-92; discussion 1692-3. doi: 10.1016/j.athoracsur.2007.04.076.
Malignant pleural mesothelioma is a locally aggressive tumor that is usually fatal. Extrapleural pneumonectomy (EPP) followed by hemithoracic irradiation has shown promise, but local failure remains a significant problem. To improve local control, we have used intensity-modulated radiation therapy (IMRT) as it allows better dose distribution to regions at risk of recurrence as well as reduced radiation to surrounding organs.
One hundred consecutive patients underwent EPP. At a median interval of 2.5 months from surgery, 63 patients received IMRT (median dose 45 Gy) with curative intent. Chemotherapy was not routinely administered.
Tumors were right sided in 66 patients (66%) and nonepithelioid in 33 (33%). American Joint Committee on Cancer pathology stage was I in 6 patients (6%), II in 7 (7%), III in 72 (72%), and IV (T4) in 15 (15%). Fifty-four patients (54%) had ipsilateral nodal metastases. Perioperative mortality was 8%. Median overall survival (n = 100) was 10.2 months. For patients who received IMRT (n = 63), median overall and 3-year survival was 14.2 months and 20%. Of these, node-negative patients with epithelioid histology (n = 18) had median and 3-year survival of 28 months and 41%. Distant recurrences occurred in 33 of 61 evaluable patients (54%). Eight patients (13%) had local or regional recurrence, 5 of whom also recurred distally. Only 3 patients (5%) had recurrence within the irradiated field.
Intensity-modulated radiation therapy after EPP results in excellent local control for malignant pleural mesothelioma; however, distant metastases remain a significant problem and limit survival. This provides a strong rationale for combining aggressive local regimens with systemic therapy.
恶性胸膜间皮瘤是一种具有局部侵袭性的肿瘤，通常是致命的。胸膜外全肺切除术（EPP）联合半胸照射已显示出前景，但局部复发仍然是一个重大问题。为了改善局部控制，我们采用了调强放射治疗（IMRT），因为它能更好地将剂量分布到有复发风险的区域，并减少对周围器官的辐射。
连续100例患者接受了EPP。术后中位间隔2.5个月时，63例患者接受了旨在治愈的IMRT（中位剂量45 Gy）。未常规进行化疗。
66例患者（66%）肿瘤位于右侧，33例（33%）为非上皮样肿瘤。美国癌症联合委员会病理分期为I期6例（6%），II期7例（7%），III期72例（72%），IV期（T4）15例（15%）。54例患者（54%）有同侧淋巴结转移。围手术期死亡率为8%。总体中位生存期（n = 100）为10.2个月。接受IMRT的患者（n = 63），总体中位生存期和3年生存率分别为14.2个月和20%。其中，组织学为上皮样且无淋巴结转移的患者（n = 18），中位生存期和3年生存率分别为28个月和41%。61例可评估患者中有33例（54%）发生远处复发。8例患者（13%）出现局部或区域复发，其中5例同时有远处复发。仅3例患者（5%）在照射野内复发。
EPP后调强放射治疗对恶性胸膜间皮瘤可实现良好的局部控制；然而，远处转移仍然是一个重大问题并限制了生存率。这为积极的局部治疗方案与全身治疗相结合提供了有力的理论依据。
