Elsevier

European Journal of Cancer

Volume 47, Issue 14, September 2011, Pages 2143-2149
European Journal of Cancer

Re-evaluating the role of palliative radiotherapy in malignant pleural mesothelioma

https://doi.org/10.1016/j.ejca.2011.05.012Get rights and content

Abstract

Purpose

To determine the objective response rate of malignant pleural mesothelioma (MPM) to short course radiation therapy.

Methods

We reviewed the cases of 54 patients with advanced MPM who were treated with palliative radiotherapy according to a standardised institutional policy. Pre- and post-treatment computed tomography scans were used to assess response.

Results

Fifty-seven percent of patients reported some improvement in their symptoms following radiotherapy. The radiology response rate was 43% (22 patients had a partial response and 1 patient a complete response). Response to treatment was correlated with the European Organisation for Research and Treatment of Cancer (EORTC) prognostic index (p = 0.001), performance status (p = 0.02) and histological subtype (p = 0.04). In the EORTC good prognosis group 56% of patients responded, compared with only 7% in the poor prognosis group (p = 0.001). The median survivals from diagnosis and from the start of radiotherapy were 11.3 months and 5.2 months, respectively. Survival following treatment was correlated with the EORTC prognostic index (p < 0.001), histological subtype (p < 0.001), performance status (p = 0.001), treatment response (p = 0.002) and haemoglobin level (0.02). The EORTC good and poor prognostic groups had survivals of 7.1 and 2.1 months, respectively (p < 0.001). Neither tumour volume nor stage were associated with prognosis.

Conclusions

Palliative radiotherapy produces a response rate in MPM that is equivalent to chemotherapy. The EORTC prognostic index can be used to select patients who are most likely to benefit from this treatment.

Introduction

Malignant pleural mesothelioma (MPM) is almost invariably a fatal illness. Reported median survival from diagnosis ranges between 7–12 months for patients receiving supportive care alone.1, 2, 3, 4, 5 Its incidence is rising and expected to peak within the next decade in most industrialised countries.6 Radical surgery has been advocated for patients with good performance status and early stage disease.7 However, the curative potential of this approach is debated and the available surgical techniques are only applicable to a small minority of patients. Trials of palliative chemotherapy generally report response rates of up to 20% for single agent and up to 45% for multi-agent regimens.8, 9, 10 The current standard of care is the combination of pemetrexed and cisplatin which produces a 41% response rate and a median survival of 12 months.10 However, there remains some doubt about the true magnitude of the survival benefit produced by chemotherapy5 and, for the majority of patients, symptom palliation remains the principal goal of treatment.

Although traditionally thought to be a radioresistant tumour, cell lines derived from MPM are in fact more sensitive to radiation than those from non-small-cell lung cancers.11 Clinical reports have also confirmed that radiation therapy can palliate chest pain in approximately 60% of patients with MPM, although the methodology for recording symptomatic benefit in these studies is suboptimal by modern standards.12, 13, 14 However, the absence of randomised trial data led a recent Cochrane review to conclude that the indications for radiotherapy in MPM are essentially unproven.15

For the last decade our institutional policy for patients with MPM and severe or intractable chest pain has been to deliver intermediate dose radiotherapy to sites of symptomatic disease in the hemithorax. In this paper we summarise the results of this approach. In contrast to previous series our report is unique in three important respects. Firstly, modern radiotherapy technology has been used to both accurately target sites of disease and shield adjacent normal tissues. Secondly, we have assessed the objective radiological response rate to radiation with follow-up scans and thirdly, we have analysed the predictive value of clinico-pathological factors in identifying patients who are most likely to benefit from this treatment.

Section snippets

Patients and methods

Between January 2002 and December 2008, 195 patients were referred to the Gloucestershire Oncology Centre for treatment of MPM. We retrospectively identified 54 patients (28%) from within this group who had received intermediate dose palliative radiotherapy at some stage in the course of their illness. For these patients the initial histological diagnosis had been made by either video-assisted thoracic surgery (24), computed tomography guided biopsy (19), freehand/ultrasound guided biopsy (6)

Results

Twenty-two patients had a partial response and 1 patient a complete response within the treatment field giving an overall radiological response rate of 43% (Fig. 1). Fifteen patients (28%) had stable disease, 4 patients (7%) experienced disease progression and 12 patients could not be evaluated due to clinical deterioration which made further imaging inappropriate. The median change in the baseline measurement for evaluable patients was a decrease of 32%. Outside the radiotherapy field

Discussion

There are three main indications for radiotherapy in the management of MPM. Prophylactic treatment is used to reduce the risk of recurrence at sites of diagnostic or therapeutic intervention. Seeding of malignant cells along such instrument tracts occurs in up to 40% of patients.22 A small but influential study demonstrated that radiation therapy was effective in reducing the risk of malignant spread along exit sites, although a more recent trial has failed to confirm this finding.22, 23

High

Conflict of interest statement

None declared.

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