Intensity-modulated radiation therapy with simultaneous integrated boost in unresected left-sided pleural mesothelioma: a case report

Our plain-English summary of Intensity-modulated radiation therapy with simultaneous integrated boost in unresected left-sided pleural mesothelioma: a case report, by S. Cilla, C. Digesú, G. Silvano, et al (Tumori, 2010).

The study

• Authors: S. Cilla, C. Digesú, G. Silvano, G. Macchia, M. Massaccesi, F. Deodato, G.D. Padula, A. Fidanzio, A. Piermattei, A.G. Morganti
• Journal: Tumori
• Published: 2010;96(4):618-22
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

A 77-year-old male patient with unresected malignant pleural mesothelioma, clinical stage T3N0M0 according to the New International Staging System for Diffuse Malignant Pleural Mesothelioma, received intensity-modulated radiotherapy (IMRT) with a simultaneous integrated boost (SIB) after 6 cycles of chemotherapy with cisplatin and pemetrexed. SIB-IMRT delivered 40.5 Gy (1.5 Gy/fraction) to the left pleura and 50 Gy (1.85 Gy/fraction) to the sites of macroscopic disease. Radiotherapy was well tolerated. Two months after the end of radiotherapy the patient showed grade 2 lung toxicity (febrile episodes accompanied by dry cough) that was successfully treated with steroid therapy. Local control lasted for 2 years after SIB-IMRT. Then the tumor recurred marginally to the radiation field and the patient underwent chemotherapy with pemetrexed. Three years from the diagnosis, the patient is alive and in good general condition. He only takes prednisone 5 mg/daily for exertional dyspnea. To the best of our knowledge this is the first reported use of SIB-IMRT in unresected malignant pleural mesothelioma. Considering the dosimetric advantages of SIB-IMRT and the clinical results observed in our patient, additional evaluation of this technique seems justified.

In plain English

This article was a case report about one patient. In July 2006 a 77-year-old man with epithelioid malignant pleural mesothelioma on the left side, staged T3N0M0, was referred to a radiotherapy unit in Campobasso, Italy. Surgery was ruled out because of his age, and he had already received 6 cycles of cisplatin and pemetrexed chemotherapy. He was then treated with intensity-modulated radiotherapy using a simultaneous integrated boost. This delivered 50.0 Gy to three visible tumor lesions and 40.5 Gy to the whole left pleural space. The treatment plan did not meet the dose limits set for the lungs. During treatment he had mild (grade 1) esophageal, skin and blood toxicity. About two months after treatment he developed fevers with dry cough, rated as grade 2 lung toxicity, and was given prednisone. Twenty months after radiotherapy the tumor recurred on the diaphragm, in an area that had received 24% to 42% of the prescribed dose, and he had further pemetrexed. In January 2009, 3 years from diagnosis, he was alive and in good general condition. The authors concluded that further evaluation of the technique seems justified. The article does not discuss asbestos exposure.

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: case report (one patient)
• Who was studied: One 77-year-old man with unresectable left-sided epithelioid malignant pleural mesothelioma, clinical stage T3N0M0, diagnosed in January 2006 and referred in July 2006 to a radiotherapy unit at the Catholic University of Campobasso, Italy; surgery was excluded because of his age
• Exposure: Not reported: the article does not describe asbestos or any other cause of the disease. What it studied was a treatment: intensity-modulated radiotherapy with a simultaneous integrated boost (50.0 Gy at 1.85 Gy per fraction to the visible tumor, 40.5 Gy at 1.50 Gy per fraction to the left pleural space), given after 6 cycles of cisplatin and pemetrexed.
• Main results:
  • The radiotherapy plan stayed within dose limits for other organs but did not meet the V20Gy and V30Gy limits for the lungs. It was accepted because the differences were within 10%.
  • During radiotherapy the patient had acute grade 1 esophageal, grade 1 skin and grade 1 blood-count (white cells and platelets) toxicity.
  • Two months after radiotherapy ended, the patient had fevers with dry cough (grade 2 lung toxicity), which was treated with prednisone 5 mg daily.
  • Twenty months after radiotherapy the tumor recurred on the diaphragm. The recurrence was in a region that had received between 24% and 42% of the prescribed dose.
  • After the recurrence the patient received 6 cycles of pemetrexed (March to August 2008). A September 2008 CT scan showed stable disease in the chest.
  • In January 2009, 3 years from diagnosis, the patient was alive and in good general condition, taking prednisone 5 mg daily for breathlessness on exertion.
• The authors' conclusion: The authors stated this was, to their knowledge, the first reported use of this technique in unresected malignant pleural mesothelioma. They concluded that the dosimetric advantages and this patient's clinical results justify further evaluation of the technique.
• Limitations the authors state:
  • The authors stated that the 10-mm lower margin used was likely too close to adequately cover the diaphragmatic pleura without breathing control. The recurrence occurred at the diaphragm.
  • The authors noted that particular attention is needed to lung dose limits because of the high risk of toxicity. The plan in this case exceeded those limits.

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, Staging, Chemotherapy, Cisplatin, Pemetrexed (Alimta), Pleura, Dyspnea.

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