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J Thorac Cardiovasc Surg 2001;122:788-795
© 2001 The American Association for Thoracic Surgery

General Thoracic Surgery

A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma

Valerie W. Rusch, MDa, Kenneth Rosenzweig, MDb, Ennapadam Venkatraman, PhDc, Larry Leon, MSc, Adam Raben, MDb, Louis Harrison, MDb, Manjit S. Bains, MDa, Robert J. Downey, MDa, Robert J. Ginsberg, MDa

From the Thoracic Service, Department of Surgery,a the Department of Radiation Oncology,b and the Biostatistics Service, Department of Epidemiology and Biostatistics,c Memorial Sloan-Kettering Cancer Center, New York, NY.

Presented in part at the 2000 Meeting of the American Society of Clinical Oncology.

Received for publication Feb 1, 2001. Revisions requested March 22, 2001; revisions received April 18, 2001. Accepted for publication April 19, 2001. Address for reprints: Valerie W. Rusch, MD, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (E-mail: ruschv{at}mskcc.org).

Background: Surgical resection of malignant pleural mesothelioma is reported to have up to an 80% rate of local recurrence. We performed a phase II trial of high-dose hemithoracic radiation after complete resection to determine feasibility and to estimate rates of local recurrence and survival.
Methods: Patients were eligible if they had a resectable tumor, as determined by computed tomographic scanning, and adequate cardiopulmonary function for extrapleural pneumonectomy or pleurectomy/decortication. After complete resection, patients received hemithoracic radiation (54 Gy) and then were followed up with serial computed tomographic scanning.
Results: From 1995 to 1998, 88 patients (73 men and 15 women; median age, 62.5 years) were entered into the study. The operations performed included 62 extrapleural pneumonectomies (70%) and 5 pleurectomies/decortications; procedures for exploration only were performed in 21 patients. Seven (7.9%) patients died postoperatively. Adjuvant radiation administered to 57 patients (54 undergoing extrapleural pneumonectomy and 3 undergoing pleurectomy/decortication) at a median dose of 54 Gy was well tolerated (grade 0-2 fatigue, esophagitis), except for one late esophageal fistula. The median survival was 33.8 months for stage I and II tumors but only 10 months for stage III and IV tumors (P = .04). For the patients undergoing extrapleural pneumonectomy, the sites of recurrence were locoregional in 2, locoregional and distant in 5, and distant only in 30.
Conclusion: Hemithoracic radiation after complete surgical resection at a dose not previously reported is feasible. This approach dramatically reduces local recurrence and is associated with prolonged survival for early-stage tumors. Stage III disease has a high risk of early distant relapse and should be considered for trials of systemic therapy added to this regimen of resection and radiation.




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