Induction radiotherapy and mesothelioma surgery

Laura L. Donahoe, BC John Cho, Marc de Perrot


Malignant pleural mesothelioma (MPM) continues to be one of the most difficult malignancies to diagnose and treat. Despite many attempts to improve the prognosis, the disease remains almost uniformly fatal with little hope for long-term survival. Many studies of radiation and surgery, either alone or combined, have been performed, but the results of treatment remain poor and most patients recur either locally or distally. In an effort to prolong survival and improve the prognosis of MPM, the Surgery for Mesothelioma After Radiation Therapy (SMART) trial was developed. Based on the idea that local control, and potentially overall survival, could be improved with high-dose radiation followed by aggressive surgery, this protocol involves a total of 25 Gy of radiation delivered in 5 daily fractions over one week to the entire ipsilateral hemithorax by intensity modulated radiation therapy (IMRT) with a concomitant boost of 5 Gy to volumes at high risk based on computed tomography (CT) and positron emission tomography (PET) scan findings. Within two weeks of completion of the radiation therapy, extra-pleural pneumonectomy (EPP) is performed. The interim results of this study have shown encouraging outcomes for select patients with MPM.