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

Background: Surgical resection of malignant pleural mesothelioma is reporte d to have up to an 80% rate of local recurrence. We performed a phase II tr ial of high-dose hemithoracic radiation after complete resection to determi ne feasibility and to estimate rates of local recurrence and survival. Methods: Patients were eligible if they had a resectable tumor, as determin ed 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, 6 2.5 years) were entered into the study. The operations performed included 6 2 extrapleural pneumonectomies (70%) and 5 pleurectomies/decortications; pr ocedures for exploration only were performed in 21 patients. Seven (7.9%) p atients died postoperatively. Adjuvant radiation administered to 57 patient s (54 undergoing extrapleural pneumonectomy and 3 undergoing pleurectomy/de cortication) at a median dose of 54 Gy was well tolerated (grade 0-2 fatigu e, esophagitis), except for one late esophageal fistula. The median surviva l was 33.8 months for stage I and II tumors but only 10 months for stage II I and IV tumors (P =.04). For the patients undergoing extrapleural pneumone ctomy, the sites of recurrence were locoregional in 2, locoregional and dis tant in 5, and distant only in 30. Conclusion: Hemithoracic radiation after complete surgical resection at a d ose 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 sho uld be considered for trials of systemic therapy added to this regimen of r esection and radiation.