Impact of Neoadjuvant and Adjuvant Pleural Intensity-Modulated Radiotherapy in Multimodality Treatment for Malignant Pleural Mesothelioma

Our plain-English summary of Impact of Neoadjuvant and Adjuvant Pleural Intensity-Modulated Radiotherapy in Multimodality Treatment for Malignant Pleural Mesothelioma, by B. Mosleh, S. Schwarz, A. Cho, et al (Thoracic Cancer, 2025).

The study

• Authors: B. Mosleh, S. Schwarz, A. Cho, K. Sinn, A. Steindl, S. Zöchbauer-Müller, W.J. Köstler, K. Dieckmann, M. Heilmann, J. Widder, D. Gompelmann, C. Aigner, T. Klikovits, M.A. Hoda
• Journal: Thoracic Cancer
• Published: 2025;16(5):e70024
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Few malignancies provoke as many controversies about treatment as pleural mesothelioma. There is limited experience with novel radiotherapy techniques worldwide in adjuvant and particularly in neoadjuvant settings within multimodality treatment. The objective of the current study was to investigate the long-term outcome of neoadjuvant and adjuvant pleural intensity-modulated radiotherapy (IMRT) combined with macroscopic complete resection with or without chemotherapy.

Methods: We retrospectively analyzed a consecutive cohort of 59 patients who were diagnosed with pleural mesothelioma and underwent multimodality treatment including macroscopic complete resection and neoadjuvant or adjuvant IMRT between 2005 and 2019 at the Department of Thoracic Surgery, Medical University of Vienna, Austria.

Results: In total, 59 patients (median age 59 years; IQR 54-66, male, n = 48; 81%) were included. Forty-seven patients underwent trimodality treatment consisting of induction chemotherapy, extrapleural pneumonectomy, and adjuvant IMRT. Novel neoadjuvant IMRT with (n = 9) or without (n = 3) chemotherapy followed by extrapleural pneumonectomy was performed in 12 patients. Median overall survival (OS) of all patients was 23.2 months (95% CI; 18.1-28.2) and 3- and 5-year survival rates were 33% and 28%, respectively. Survival was comparable between therapies including neoadjuvant versus adjuvant IMRT (median OS 17.5 vs. 24.0 months, p = 0.39).

Conclusions: Neoadjuvant pleural IMRT has been investigated as a novel treatment option for highly selected cases in pleural mesothelioma. Neoadjuvant IMRT was effective and safe in patients treated in a high-volume institution but showed no relevant survival benefit compared to adjuvant IMRT within multimodality treatment.

© 2025 The Author(s). Thoracic Cancer published by John Wiley & Sons Australia, Ltd.

In plain English

This retrospective study reviewed 59 patients with pleural mesothelioma treated between 2005 and 2019 at the Medical University of Vienna, Austria. All had extrapleural pneumonectomy (removal of the lung and pleura) and intensity-modulated radiotherapy (IMRT). Forty-seven had chemotherapy, then surgery, then radiotherapy (the adjuvant group). Twelve had radiotherapy before surgery, 9 of them after chemotherapy (the neoadjuvant group). The article gives no information on asbestos exposure. Median overall survival for all patients was 23.2 months (95% confidence interval 18.1 to 28.2 months), and 3- and 5-year survival rates were 33% and 28%. Median survival was 17.5 months in the neoadjuvant group and 24.0 months in the adjuvant group. This difference was not statistically significant (p = 0.39), and results were similar after propensity score matching. Postoperative complications occurred in 42% of patients, and one adjuvant-group patient died of radiation pneumonitis. The authors concluded that neoadjuvant IMRT was effective and safe at a high-volume institution but showed no relevant survival benefit over adjuvant IMRT. They named the retrospective single-center design and small patient numbers as limitations.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of a prospective single-center database (treatment outcome study)
• Who was studied: 59 patients with histologically confirmed pleural mesothelioma (median age 59 years, 48 male) treated with extrapleural pneumonectomy and IMRT, with or without chemotherapy, between 2005 and 2019 at the Department of Thoracic Surgery, Medical University of Vienna, Austria
• Exposure: No asbestos exposure information is reported. The study compared two treatment sequences. In the neoadjuvant group (n = 12, treated 2016 to 2018), IMRT was given before extrapleural pneumonectomy: 9 patients first had platinum-pemetrexed chemotherapy and 3 had no chemotherapy. In the adjuvant group (n = 47), patients had induction chemotherapy, then extrapleural pneumonectomy, then IMRT.
• Main results:
  • Macroscopic complete resection was achieved in all 59 patients
  • Median overall survival for all patients was 23.2 months (95% CI 18.1 to 28.2); 3- and 5-year survival rates were 33% and 28%
  • Median overall survival was 24.0 months in the adjuvant IMRT group vs. 17.5 months in the neoadjuvant IMRT group, p = 0.39 (not statistically significant)
  • Disease-free survival was 13.2 months for all patients (95% CI 7.7 to 18.9); it was 7.9 months in the neoadjuvant group vs. 13.7 months in the adjuvant group, p = 0.37 (no significant difference)
  • After 1:2 propensity score matching (24 adjuvant vs. 12 neoadjuvant patients), median overall survival was 17.5 months (neoadjuvant) vs. 24.2 months (adjuvant), p = 0.40
  • Postoperative complications occurred in 42% of the entire cohort (25/59); 13/59 (22%) had grade 3 or higher adverse events
  • One treatment-related death occurred, from fatal radiation pneumonitis during adjuvant IMRT; perioperative mortality was nil
  • 32 of 59 patients (54%) developed recurrence during follow-up, most often in the ipsilateral thoracic wall (16/59, 27%)
• The authors' conclusion: The authors concluded that neoadjuvant IMRT was effective and safe in patients treated at a high-volume institution but showed no relevant survival benefit compared to adjuvant IMRT within multimodality treatment
• Limitations the authors state:
  • Retrospective single-center design and relatively small number of patients, which may limit generalizability

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Intensity-Modulated Radiation Therapy (IMRT), Pleural Mesothelioma, Chemotherapy, Thoracic Surgery, Extrapleural Pneumonectomy (EPP), Median Overall Survival.

Related studies

• Long-term results in malignant pleural mesothelioma treated with neoadjuvant chemotherapy, extrapleural pneumonectomy and intensity-modulated radiotherapy — C. Thieke, N.H. Nicolay, et al. (2015)
• Adjuvant intensity-modulated proton therapy in malignant pleural mesothelioma. A comparison with intensity-modulated radiotherapy and a spot size variation assessment — S. Lorentini, M. Amichetti, et al. (2012)
• Intensity-modulated radiotherapy after extrapleural pneumonectomy in the combined-modality treatment of malignant pleural mesothelioma — A. Chi, Z. Liao, et al. (2011)
• Extra-pleural pneumonectomy in the era of image-guided intensity-modulated radiotherapy — M. Trovo, D. Franceschini, et al. (2019)
• Intensity-modulated radiotherapy is a safe and effective treatment for localized malignant pleural mesothelioma — M. Simon, T. Shochat, et al. (2018)
• Intensity-modulated radiotherapy and volumetric-modulated arc therapy for malignant pleural mesothelioma after extrapleural pleuropneumonectomy — J. Krayenbuehl, O. Riesterer, et al. (2013)

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