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Stereotactic Intensity-Modulated Radiation Therapy (IMRT) And Inverse Treatment Planning For Advanced Pleural Mesothelioma

M. Muenter, S. Nill, C. Thilmann, H. Hof, A. Hoess, P. Haering, M. Partridge, C. Manegold, M. Wannenmacher, J. Debus
Published 2003 · Medicine

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Background and Purpose: Complex-shaped malignant pleural mesotheliomas (MPMs) with challenging volumes are extremely difficult to treat by conventional radiotherapy due to tolerance doses of the surrounding normal tissue. In a feasibility study, we evaluated if inversely planned stereotactic intensity-modulated radiation therapy (IMRT) could be applied in the treatment of MPM. Patients and Methods: Results: Conclusion: Patients and Methods: Eight patients with unresectable lesions were treated after failure of chemotherapy. All patients were positioned using noninvasive patient fixation techniques which can be attached to the applied extracranial stereotactic system. Due to craniocaudal extension of the tumor, it was necessary to develop a special software attached to the inverse planning program KonRad, which can connect two inverse treatment plans and consider the applied dose of the first treatment plan in the area of the matchline of the second treatment plan. Results: Except for one patient, in whom radiotherapy was canceled due to abdominal metastasis, treatment could be completed in all patients and was well tolerated. Median survival after diagnosis was 20 months and after IMRT 6.5 months. Therefore, both the 1-year actuarial overall survival from the start of radiotherapy and the 2-year actuarial overall survival since diagnosis were 28%. IMRT did not result in clinically significant acute side effects. By using the described inverse planning software, overor underdosage in the region of the field matchline could be prevented. Pure treatment time ranged between 10 and 21 min. Conclusion: This study showed that IMRT is feasible in advanced unresectable MPM. The presented possibilities of stereotactic IMRT in the treatment of MPM will justify the evaluation of IMRT in early-stage pleural mesothelioma combined with chemotherapy in a study protocol, in order to improve the outcome of these patients. Furthermore, dose escalation should be possible by using IMRT.Hintergrund und Ziel: Komplex geformte bösartige Pleuramesotheliome mit einem ausgedehnten Volumen sind aufgrund der Toleranzdosen des umgebenden Normalgewebes nur sehr schwierig mit Hilfe der konventionellen Strahlentherapie zu behandeln. In einer Machbarkeitsstudie wurde untersucht, ob sich die stereotaktisch geplante intensitätsmodulierte Strahlentherapie (IMRT) zur Behandlung maligner Pleuramesotheliome eignet. Patienten und Methodik: Acht Patienten mit nicht resektablen Tumoren wurden bei Tumorprogress nach Chemotherapie behandelt. Alle Patienten wurden mit Hilfe eines nichtinvasiven Positionierungssystems gelagert, das in Verbindung mit einem Ganzkörperstereotaxiesystem verwendet wird. Aufgrund der kraniokaudalen Ausdehnung der Tumoren war es notwendig, eine spezielle, mit dem inversen Planungsprogramm KonRad verbundene Software zu entwickeln, die zwei unterschiedliche Bestrahlungspläne zusammenfügen kann. Die Dosisverteilung des ersten Bestrahlungsplans wird bei der Erstellung des zweiten Bestrahlungsplans berücksichtigt. Ergebnisse: Die Behandlung ließ sich bei sieben Patienten vollständig durchführen und wurde gut toleriert. Lediglich bei einem Patienten musste sie wegen einer abdominellen Metastase abgebrochen werden. Das mediane Überleben nach Diagnosestellung betrug 20 Monate und nach IMRT 6,5 Monate. Sowohl das aktuarische 1-Jahres-Überleben bei Beginn der Strahlentherapie als auch das 2-Jahres-Überleben nach Diagnosestellung lagen bei 28%. Nach der IMRT-Behandlung wurden keine klinisch signifikanten akuten Nebenwirkungen festgestellt. Mit Hilfe der verwendeten inversen Planungssoftware konnten Über- und Unterdosierungen im Bereich des Feldanschlusses vermieden werden. Die eigentliche Behandlungszeit variierte zwischen 10 und 21 min. Schlussfolgerung: Diese Studie zeigt, dass die IMRT bei fortgeschrittenen nicht resektablen Pleuramesotheliomen durchführbar ist. Die Möglichkeiten der vorgestellten stereotaktischen IMRT-Technik rechtfertigen die Erstellung eines Studienprotokolls in frühen Tumorstadien kombiniert mit einer Chemotherapie. Damit könnte die Prognose der Patienten verbessert werden. Des Weiteren sollte durch die IMRT eine Dosiseskalation möglich sein.
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