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Trimodality Treatment In Malignant Pleural Mesothelioma: An Ordeal Or The Real Deal?

N. Mummudi, A. Khan, A. Tibdewal, R. Kumar, S. Jiwnani, G. Karimundackal, P. S. C, J. Agarwal
Published 2020 · Medicine

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BACKGROUND: Malignant Pleural Mesothelioma is an uncommon and aggressive disease associated with asbestos exposure. Management of MPM is complex and controversial as there is paucity of good quality evidence. Multimodality treatment with surgery, systemic therapy and radiation therapy is an option in non-metastatic MPM. We intend to analyze toxicity and outcomes in patients who received trimodality treatment for non-metastatic MPM at our institution. METHODS and MATERIALS: We reviewed the electronic medical records of surgically managed MPM patients at our institution in the last decade. Patient details, disease characteristics and treatment information were retrieved from the institutional electronic medical record and radiation oncology information system. Dosimetric parameters of target volume and organs at risk were documented from Eclipse workstation (v13.6, Varian medical systems). SPSS was used for statistical analysis. RESULTS: Between January 2008 and October 2018, 21 patients (17 male and 4 female) underwent surgery for MPM, all but 2 patients underwent extra-pleural pneumonectomy (EPP). Primary was located in the right and left in 11 and 10 patients respectively. Epithelioid MPM was the commonest histology (17 patients: 81%). Resection was R0 in 18 patients and R2 in 2 patients. Four patients had minor complications like wound erythema, wound seroma with cellulitis and hypotension and 8 Patients had major complications like pneumonia, rib fracture, pulmonary hypertension and pulmonary stump thrombus. All patients received neoadjuvant Pemetrexed/platinum doublet chemotherapy, except for 2. Fourteen patients received adjuvant hemithoracic RT; of these, 2 underwent treatment elsewhere and 2 were treated with conventional technique. Ten patients treated with conformal technique at our institute and dosimetric data was available for analysis. Average time to start RT after surgery was 51 days (range 32 to 82 days). All patients were treated with conformal technique using IMRT/VMAT to a dose of 45Gy in 25 fractions; one patient received a further boost of 5.4Gy. Mean overall RT duration was 35 days (range 30 to 42 days). Acute toxicity was uncommon; Grade I/II Pneumonitis was seen in 4 patients. One patient developed grade III acute lung toxicity unrelated to RT. At a median follow up of 25 months, 8 patients developed progressive disease. Eight patients had died, of whom six died due to disease and two died in immediate post op period. Two-year DFS and OS were 58% and 73% respectively. CONCLUSION: In spite of the extensive surgery and complex hemithoracic RT, we demonstrated excellent dosimetric, toxicity profile and favorable outcomes in non-metastatic MPM.
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