Abstract
Prophylactic irradiation to the chest wall after diagnostic or therapeutic procedures in patients with malignant pleural mesothelioma (MPM) has been a widespread practice across Europe, although the efficacy of this treatment is uncertain. In this study, we aimed to determine the efficacy of prophylactic radiotherapy in reducing the incidence of chest wall metastases (CWM) after a procedure in MPM. After undergoing a chest wall procedure, patients with MPM were randomly assigned to receive prophylactic radiotherapy (within 42 days of the procedure) or no radiotherapy. Open thoracotomies, needle biopsies, and indwelling pleural catheters were excluded. Prophylactic radiotherapy was delivered at a dose of 21 Gy in three fractions over three consecutive working days, using a single electron field adapted to maximize coverage of the tract from skin surface to pleura. The primary outcome was the incidence of CWM within 6 months from random assignment, assessed in the intention-to-treat population. Stratification factors included epithelioid histology and intention to give chemotherapy. Between July 30, 2012, and December 12, 2015, 375 patients were recruited from 54 centers and randomly assigned to receive prophylactic radiotherapy (n = 186) or no prophylactic radiotherapy (n = 189). Participants were well matched at baseline. No significant difference was seen in the incidence of CWM at 6 months between the prophylactic radiotherapy and no radiotherapy groups (no. [%]: 6 [3.2] v 10 [5.3], respectively; odds ratio, 0.60; 95% CI, 0.17 to 1.86; P = .44). Skin toxicity was the most common radiotherapy-related adverse event in the prophylactic radiotherapy group, with 96 patients (51.6%) receiving grade 1; 19 (10.2%), grade 2; and 1 (0.5%) grade 3 radiation dermatitis (Common Terminology Criteria for Adverse Events, version 4.0). There is no role for the routine use of prophylactic irradiation to chest wall procedure sites in patients with MPM.
Highlights
Malignant pleural mesothelioma (MPM) is almost exclusively linked to asbestos exposure and has a latency period of 12 to 50 or more years.[1,2,3] Survival rates are gradually improving but remain poor, with 2-year survival ranging from 17% to 46%, according to clinical stage, in the United States.[4]The diagnosis and treatment of MPM usually involves an invasive procedure at the chest wall, which can cause tumor-cell seeding at the site of the procedure and result in the development of a subcutaneous tumor
No significant difference was seen in the incidence of chest wall metastases (CWM) at 6 months between the prophylactic radiotherapy and no radiotherapy groups
There is no role for the routine use of prophylactic irradiation to chest wall procedure sites in patients with MPM
Summary
Malignant pleural mesothelioma (MPM) is almost exclusively linked to asbestos exposure and has a latency period of 12 to 50 or more years.[1,2,3] Survival rates are gradually improving but remain poor, with 2-year survival ranging from 17% to 46%, according to clinical stage, in the United States.[4]. The diagnosis and treatment of MPM usually involves an invasive procedure at the chest wall, which can cause tumor-cell seeding at the site of the procedure and result in the development of a subcutaneous tumor. Studies have reported that the incidence of chest wall metastases (CWM) ranges from 2% to 50%.5-13. To minimize tumor seeding and prevent the development of CWM, it has been widespread practice for the last two decades to deliver prophylactic radiotherapy to the site of the chest wall procedure,[14,15] the efficacy of this approach is uncertain and based on conflicting data from underpowered clinical trials conducted before the era of chemotherapy.[16,17,18,19,20] This has resulted in conflicting recommendations in international guidelines and consensus that suitably powered randomized trials are needed.[21,22,23,24] In the current trial, the aim was to determine whether prophylactic radiotherapy after a chest wall procedure reduces the incidence of CWM
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