Arnold David T, Clive Amelia O
Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
Curr Opin Pulm Med. 2017 Jul;23(4):357-364. doi: 10.1097/MCP.0000000000000385.
Malignant pleural mesothelioma is an aggressive malignancy with a very poor prognosis. The majority of patients require pleural procedures for diagnostic or fluid management purposes. Damage to the pleura during these procedures can lead to procedure tract metastases (PTMs), with increasing risk from larger interventions. Prophylactic radiotherapy to these sites is a controversial topic with conflicting results from trial data. In this review, we summarize the recent evidence.
Four RCTs have been published on this topic, with another in follow-up. The earliest, from a cohort of 40 patients, strongly advocated the use of prophylactic radiotherapy. More recent trials, most notably the Surgical and large bore procedures in Malignant pleural mesothelioma And Radiotherapy Trial (SMART) (which randomized over 200 patients) did not demonstrate any benefit, especially when patient report symptoms and cost-effectiveness are considered. Certain subgroups demand further investigation, such as those not receiving systematic chemotherapy or with surgical intervention sites. The soon to be published Prophylactic Irradiation of Tracts (PIT) trial may help to further clarify best practice.
Recent studies have shown that prophylactic radiotherapy should not be routinely used to prevent PTMs in mesothelioma. Instead patients should undergo careful clinical follow-up to ensure PTMs are identified and treated promptly to minimize symptoms.
恶性胸膜间皮瘤是一种侵袭性恶性肿瘤，预后很差。大多数患者需要进行胸膜相关操作以达到诊断或控制胸腔积液的目的。在这些操作过程中对胸膜造成的损伤可导致手术通道转移（PTMs），较大的干预措施会增加这种风险。对这些部位进行预防性放射治疗是一个有争议的话题，试验数据的结果相互矛盾。在本综述中，我们总结了最新证据。
关于这个主题已经发表了四项随机对照试验（RCT），另一项正在随访中。最早的一项研究纳入了40名患者，强烈主张使用预防性放射治疗。最近的试验，最值得注意的是恶性胸膜间皮瘤手术及大口径操作与放射治疗试验（SMART）（该试验纳入了200多名患者）并没有显示出任何益处，尤其是在考虑患者报告的症状和成本效益时。某些亚组需要进一步研究，例如那些未接受全身化疗或有手术干预部位的患者。即将发表的手术通道预防性照射（PIT）试验可能有助于进一步阐明最佳实践。
最近的研究表明，预防性放射治疗不应常规用于预防间皮瘤中的手术通道转移。相反，患者应接受仔细的临床随访，以确保及时发现并治疗手术通道转移，从而将症状降至最低。
