The Role of Radiotherapy After Pleurectomy/Decortication for Malignant Pleural Mesothelioma: State of the Art

Our plain-English summary of The Role of Radiotherapy After Pleurectomy/Decortication for Malignant Pleural Mesothelioma: State of the Art, by M. Andolfi, M. Salati, M. Refai (Journal of Personalized Medicine, 2025).

The study

• Authors: M. Andolfi, M. Salati, M. Refai
• Journal: Journal of Personalized Medicine
• Published: 2025;15(12)
• Type of article: Review
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Considering the increased need to deliver adjuvant radiotherapy (RT) after pleurectomy/decortication (P/D) for malignant pleural mesothelioma (MPM) without exceeding the tolerance of the adjacent normal tissue, new advanced RT technologies have been developed. However, radiation to the whole hemithorax presents a challenge because of the increased risk of toxicity occurring with two intact radiosensitive lungs. The aim of this study is to systematically review the literature in order to assess the role of radiotherapy after P/D for MPM, based on the evidence published so far. Methods: We conducted this systematic review according to PRISMA guidelines and registered in an international public register of systematic review (PROSPERO). A PubMed and Cochrane database search was performed to identify articles published from 2005 to 2024 regarding the role of adjuvant radiotherapy after P/D for MPM. We included only level I-III-evidence studies according to the Oxford Centre for Evidence-Based Medicine's guidance. Results: We selected 11 level II studies. Based on published reports, delivery of high-dose external beam 'conventional' RT to the entire hemithorax is not recommended in a P/D setting and hemithoracic intensity-modulated radiotherapy (IMRT) may be considered an encouraging and reasonable therapeutic option, leading to excellent loco-regional control and survival results. Conclusions: Data and experience strongly support that the ideal platform to define potential indication of the adjuvant RT is a multidisciplinary team. Moreover, given the technical difficulty of IMRT treatment, we recommend considering this treatment in experienced centers with dedicated protocols for MPM due to their ability to detect and manage side effects resulting from the disease and the treatment as well as to ensure the best and the latest treatment plan for each patient.

In plain English

This article was a systematic review of published studies and did not examine asbestos exposure. The authors searched PubMed and Cochrane for articles published from 2005 to 2024 on radiotherapy given after pleurectomy/decortication (P/D), a lung-sparing operation, for malignant pleural mesothelioma. They included 11 studies, all rated level II evidence. Eight examined intensity-modulated radiotherapy (IMRT). Across those eight, grade 2 or higher pneumonitis (radiation-related lung inflammation) ranged from 2% to 30% (mean 17.6%). Only one reported a fatal case of pneumonitis. Median overall survival ranged from 19 to 33 months (mean 23.6). Two studies of high-dose conventional radiotherapy to the whole side of the chest found significant toxicity. In one included study of 209 patients (Shaik et al.), median overall survival was 20.2 months with IMRT versus 12.3 months with conventional radiotherapy (p = 0.001). The authors concluded that IMRT seemed the most appropriate approach after P/D and neoadjuvant chemotherapy. They noted limited sample sizes, varied surgery and chemotherapy, a lack of comparative studies able to define the effect of adjuvant radiotherapy, and data coming from high-volume centers.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: systematic review following PRISMA guidelines; qualitative synthesis of published studies
• Who was studied: 11 published studies (all level II evidence) on radiotherapy after pleurectomy/decortication for malignant pleural mesothelioma, identified in PubMed and Cochrane searches covering 2005 to 2024; individual studies ranged from 10 to 209 patients, from Italy, USA, Germany and Mexico
• Exposure: No asbestos exposure was studied. The review concerned radiotherapy techniques given after P/D: mainly IMRT (including VMAT and helical tomotherapy), high-dose conventional external beam radiotherapy to the whole hemithorax, and proton therapy combined with photodynamic therapy
• Main results:
  • No level I or level III studies on the topic were found; all 11 included studies were level II
  • In the IMRT studies, grade 2 or higher pneumonitis ranged from 2% to 30% (mean 17.6%)
  • Among the IMRT studies, only one reported fatal pneumonitis, 3 months after treatment
  • Median overall survival in the IMRT studies ranged from 19 to 33 months (mean 23.6)
  • Two studies of high-dose conventional external beam radiotherapy to the entire hemithorax found significant toxicity, and the authors judged it not recommended after P/D
  • In the included Shaik et al. study of 209 patients after P/D, median overall survival was 20.2 months with IMRT vs. 12.3 months with conventional external beam radiotherapy (p = 0.001)
• The authors' conclusion: The authors concluded that radical IMRT seemed the most appropriate approach after P/D and neoadjuvant chemotherapy, with a better toxicity profile and higher median overall survival than reported for older techniques
• Limitations the authors state:
  • Limited sample sizes due to the rarity of the disease, inconsistent surgical procedures, differing chemotherapy regimens, and no comparative studies able to define the effect of adjuvant radiotherapy
  • Several studies grouped IMRT outcomes with patients who were non-operable or had only a palliative procedure
  • Data came from high-volume centers, so results may not apply to patients treated in small centers

Topics

Medical terms in this study, explained in our Lexicon: Pleurectomy/Decortication (P/D), Pleural Mesothelioma, State-of-the-Art Defense, Hemithorax, Systematic Review, Intensity-Modulated Radiation Therapy (IMRT), Multidisciplinary Team.

Related studies

• Pleurectomy/decortication, hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy, and systemic chemotherapy in patients with malignant pleural mesothelioma: a 10-year experience — L. Lang-Lazdunski, A. Bille, et al. (2015)
• A Trimodality, Four-Step Treatment including Chemotherapy, Pleurectomy/Decortication and Radiotherapy in Early-Stage Malignant Pleural Mesothelioma: A Single-Institution Retrospective Case Series Study — G. Vicidomini, C.M. Della Corte, et al. (2021)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma — V. Rusch, L. Saltz, et al. (1994)
• Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma — L. Lang-Lazdunski, A. Bille, et al. (2012)
• Extended Pleurectomy-Decortication-Based Treatment for Advanced Stage Epithelial Mesothelioma Yielding a Median Survival of Nearly Three Years — J.S. Friedberg, C.B. Simone, et al. (2017)

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