The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation

Our plain-English summary of The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation, by D.R. Gomez, A. Rimner, C.B. Simone, et al (Journal of Thoracic Oncology, 2019).

The study

• Authors: D.R. Gomez, A. Rimner, C.B. Simone, B.C.J. Cho, M. de Perrot, A.A. Adjei, R. Bueno, R.R. Gill, D.H. Harpole, M. Hesdorffer, F.R. Hirsch, A.A. Jackson, H.I. Pass, D.C. Rice, V.W. Rusch, A.S. Tsao, E. Yorke, K. Rosenzweig
• Journal: Journal of Thoracic Oncology
• Published: 2019;14(7):1172-1183
• Type of article: Review, Consensus statement
• Cited by: 57 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Detailed guidelines regarding the use of radiation therapy for malignant pleural mesothelioma (MPM) are currently lacking because of the rarity of the disease, the wide spectrum of clinical presentations, and the paucity of high-level data on individual treatment approaches.

Methods: In March 2017, a multidisciplinary meeting of mesothelioma experts was cosponsored by the U.S. National Cancer Institute, International Association for the Study of Lung Cancer Research, and Mesothelioma Applied Research Foundation. Among the outcomes of this conference was the foundation of detailed, multidisciplinary consensus guidelines.

Results: Here we present consensus recommendations on the use of radiation therapy for MPM in three discrete scenarios: (1) hemithoracic radiation therapy to be used before or after extrapleural pneumonectomy; (2) hemithoracic radiation to be used as an adjuvant to lung-sparing procedures (i.e., without pneumonectomy); and (3) palliative radiation therapy for focal symptoms caused by the disease. We discuss appropriate simulation techniques, treatment volumes, dose fractionation regimens, and normal tissue constraints. We also assess the role of particle beam therapy, specifically, proton beam therapy, for MPM.

Conclusion: The recommendations provided in this consensus statement should serve as important guidelines for developing future clinical trials of treatment approaches for MPM.

Copyright © 2019 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

In plain English

This article was an expert consensus statement, not a patient study. It followed a March 2017 expert meeting and gave radiation recommendations for malignant pleural mesothelioma. The authors noted that evidence varied and some approaches were largely experimental. For radiation to one whole side of the chest after extrapleural pneumonectomy (EPP), they recommended 45 to 54 Gy given in 1.8- to 2.0-Gy doses, keeping doses to nearby organs within limits. They did not recommend preventive radiation of procedure tracts, only of tracts shown under the microscope to contain tumor. They advised that radiation before EPP (the SMART approach) be used only in highly experienced centers within a clinical trial. They advised that whole-pleura radiation after lung-sparing surgery (IMPRINT; standard dose 50.4 Gy, reducible to meet normal-tissue limits) and proton therapy be used only in experienced centers, preferably within a trial. For symptom relief, they recommended standard regimens such as 8 Gy once, 4 Gy five times, or 3 Gy ten times. The article did not address asbestos exposure. The authors concluded the statement would guide future National Cancer Institute–sponsored mesothelioma trials.

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: Expert consensus statement (treatment recommendations), not an original study of patients
• Who was studied: No patients were studied. The recommendations concern patients with malignant pleural mesothelioma who receive radiation therapy. They came from a March 2017 multidisciplinary meeting of mesothelioma experts.
• Exposure: Not asbestos exposure. The article concerns these radiation therapy approaches for malignant pleural mesothelioma:
• radiation after or before extrapleural pneumonectomy
• procedure tract radiation
• radiation after lung-sparing surgery
• palliative radiation
• proton therapy
• Main results:
  • For whole-hemithorax radiation after extrapleural pneumonectomy, the authors recommended a total dose of 45 to 54 Gy in 1.8- to 2.0-Gy fractions. Doses to organs at risk were to stay within their constraints.
  • For patients with an R1 or R2 resection after extrapleural pneumonectomy, the authors stated that a boost to 54 to 60 Gy can be used.
  • The authors did not recommend preventive (prophylactic) radiation of procedure tracts. They did recommend radiation for procedure tracts that were histologically positive on resection.
  • The authors advised that radiation before extrapleural pneumonectomy (the SMART approach) be performed only in highly experienced centers and within a clinical trial.
  • For whole-pleura radiation in patients with two intact lungs after lung-sparing surgery (IMPRINT), the standard dose was 50.4 Gy in 28 fractions. The authors stated it may need to be adjusted to avoid exceeding normal tissue constraints, to a minimum of 45 Gy. They advised that the technique be used only in highly experienced centers, preferably within a clinical trial.
  • The authors advised that proton therapy be considered only in centers with significant experience, preferably within a clinical trial.
  • For palliative (symptom-relief) radiation, the authors recommended standard regimens for most patients with symptomatic disease.
• The authors' conclusion: The authors concluded that the consensus statement will serve as a guideline for future National Cancer Institute–sponsored mesothelioma trials.
• Limitations the authors state:
  • The authors stated that the radiation approaches discussed have varying levels of evidence and that some are largely experimental.
  • The authors acknowledged that no randomized or multi-institutional prospective data support the SMART approach.
  • The authors stated that clinical outcome data for proton therapy in malignant pleural mesothelioma are sparse.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Lung Cancer, Mesothelioma, Extrapleural Pneumonectomy (EPP), Pneumonectomy, Palliative Care, Proton Therapy, Clinical Trial.

Related studies

• Current and Future Management of Malignant Mesothelioma: A Consensus Report from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation — A.S. Tsao, O.W. Lindwasser, et al. (2018)
• Radiologic Considerations and Standardization of Malignant Pleural Mesothelioma Imaging Within Clinical Trials: Consensus Statement from the NCI Thoracic Malignancy Steering Committee - International Association for the Study of Lung Cancer - Mesothelioma Applied Research Foundation Clinical Trials Planning Meeting — R.R. Gill, A.S. Tsao, et al. (2019)
• A Proposed System Toward Standardizing Surgical-Based Treatments for Malignant Pleural Mesothelioma, From the Joint National Cancer Institute-International Association for the Study of Lung Cancer-Mesothelioma Applied Research Foundation Taskforce — J.S. Friedberg, M.J. Culligan, et al. (2019)
• The role of radiation treatment in pleural mesothelioma: Highlights of the 14th International Conference of the International mesothelioma interest group — R.M. MacRae, M. Ashton, et al. (2019)
• Reply to Waller et al. Standardizing Surgical Treatment for Mesothelioma — J.S. Friedberg, M.J. Culligan, et al. (2020)
• I-O Optimise: a novel multinational real-world research platform in thoracic malignancies — S. Ekman, F. Griesinger, et al. (2019)

Browse more research in Journal of Thoracic Oncology, or return to medical research.