Short reportPrevention of tumour seeding following thoracoscopy in mesothelioma by prophylactic radiotherapy
Abstract
To determine the usefulness of prophylactic radiotherapy following thoracoscopy or pleural aspiration in patients with mesothelioma we reviewed the case notes of patients treated at St Mary's Hospital between 1990 and 1994. Twenty patients have received treatment to 38 sites and tumour seeding was prevented in all patients available for follow-up. Four patients acted as their own controls by developing nodules at untreated sites. Prophylactic radiotherapy is highly effective in preventing tumour seeding in mesothelioma.
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Cited by (53)
Diseases of the Pleura and Mediastinum
2019, Abeloff’s Clinical OncologyMalignant pleural mesothelioma is a rare disease. Ninety percent of cases are attributed to asbestos exposure. Surgical options include extrapleural pneumonectomy or pleurectomy and decortication. The role of chemotherapy and radiation in resectable disease is controversial. For unresectable or metastatic disease, the standard treatment is the combination of a platinum drug and an antifolate drug.
Thymoma is the most common mediastinal tumor. Fifty percent of patients are symptomatic at diagnosis, and thymomas can be associated with paraneoplastic syndromes such as myasthenia gravis. Surgical resection is the standard of care. Postoperative radiation therapy should be considered for patients with stage IIB disease, close surgical margins, World Health Organization (WHO) grade B type, and tumor adherent to the pericardium. Chemotherapy may be helpful for patients with unresectable or metastatic disease. Sunitinib and PD-1/PD-L1 agents are being studied for thymoma and thymic carcinoma. Thymic carcinoids exhibit a spectrum of pathologic and clinical aggressiveness. When possible, the primary treatment is surgical resection. Radiation therapy can palliate symptomatic local and distant metastases. More aggressive atypical carcinoid tumors can be sensitive to the same chemotherapy used for other neuroendocrine cancers. When they bear octreotide receptors, somatostatin analogues or radiolabeled somatostatin analogues may be considered. Mammalian target of rapamycin (mTOR) inhibitors are promising.
The most common causes of malignant pleural effusions are lung cancer, breast cancer, lymphoma, pleural mesothelioma, and cancer of unknown primary. Common symptoms include shortness of breath and cough. Management strategies include thoracentesis, indwelling pleural catheters, and pleurodesis.
Prophylactic radiotherapy in a single fraction of 10 Gy at intervention pleural site in patient with malignant pleural mesothelioma: A retrospective monocentric cohort study
2017, Cancer/RadiotherapieLe recours à la radiothérapie prophylactique afin de prévenir les métastases des sites d’intervention pleurale dans le mésothéliome pleural malin demeure controversé et les pratiques cliniques variées. L’objectif était d’évaluer l’efficacité d’une séance unique de radiothérapie externe de 10 Gy en prévention de l’ensemencement des sites d’intervention pleurale chez des patients atteints de mésothéliome pleural malin.
Il s’agit d’une étude épidémiologique descriptive rétrospective de cohorte, incluant les patients atteints d’un mésothéliome pleural malin histologiquement prouvé irradiés en regard des sites d’intervention pleurale par des électrons de 6 à 18 MeV, entre janvier 1990 et décembre 2013 à l’institut de cancérologie de Lorraine.
Quatre-vingt-onze patients ont été traités par irradiation prophylactique des sites d’intervention pleurale, soit 120 sites d’intervention pleurale, 91 thoracoscopies, 17 thoracotomies avec drainage pleural, 12 ponctions-biopsies guidées par scanographie ou échographie. Le suivi médian était de 7 mois (intervalle interquartile entre 3 et 15 mois). La probabilité de survie globale était de 43,5 % à 12 mois, celle de survie sans progression de 43,7 %. L’incidence de la progression locale était de 8 % à 12 mois. Le temps médian écoulé entre l’irradiation et la progression locale était de 4 mois (2 ; 32). Il n’y a pas eu d’effet secondaire précoce ou tardif de grade supérieur ou égal à deux.
L’irradiation des sites d’intervention pleurale en une séance unique de 10 Gy est efficace, bien tolérée, simple, rapide et peu coûteuse.
Prophylactic radiotherapy to prevent procedure-tracts metastases from malignant pleural mesothelioma remains controversial and clinical practice varies. The purpose was to assess the efficacy of local radiotherapy in a single fraction of 10 Gy in preventing malignant seeding at intervention pleural site in patients with malignant pleural mesothelioma.
This is a retrospective cohort study, including patients with histological confirmed malignant pleural mesothelioma treated by prophylactic irradiation to prevent interventional site metastases with a unique fraction of 10 Gy with 6 to 18 MeV, from January 1990 to December 2013 in the institut de cancérologie de Lorraine (Nancy, France).
Ninety-one patients were treated by irradiation in intervention site, involving 120 intervention pleural sites, 91 thoracoscopies, 17 thoracotomies with chest drain and 12 CT or ultrasound guided needle biopsies. The median follow-up was 7 months (interquartile between 3 and 15 months). The overall survival was 43.5% at 12 months. The local progression free survival was 43.7% at 12 month. The incidence of local recurrence was 8% at 12 months. The median interval from radiotherapy to local recurrence was 4 months (2; 32). No grade II or higher toxicity was observed.
Irradiation of pleural intervention sites with a single fraction of 10 Gy is effective, well tolerated, simple, fast and cost effective.
Intratumoral macrophage phenotype and CD8<sup>+</sup> T lymphocytes as potential tools to predict local tumor outgrowth at the intervention site in malignant pleural mesothelioma
2015, Lung CancerCitation Excerpt :Whether chemotherapy prevents LTO in some patients is not known. Prophylactic irradiation of intervention track (PIT) was introduced in an attempt to prevent LTO and thus improves quality of life for these patients [13]. Three randomized controlled trials addressing this subject showed conflicting results, which may be caused by the low incidence of LTO in the non-treatment arm [3,6–8].
In patients with malignant pleural mesothelioma (MPM), local tumor outgrowth (LTO) after invasive procedures is a well-known complication. Currently, no biomarker is available to predict the occurrence of LTO. This study aims to investigate whether the tumor macrophage infiltration and phenotype of and/or the infiltration of CD8+ T-cells predicts LTO.
Ten mesothelioma patients who developed LTO were clinically and pathologically matched with 10 non-LTO mesothelioma patients. Immunohistochemistry was performed on diagnostic biopsies to determine the total TAM (CD68), the M2 TAM (CD163) and CD8+ T-cell count (CD8).
The mean M2/total TAM ratio differed between the two groups: 0.90 ± 0.09 in the LTO group versus 0.63 ± 0.09 in patients without LTO (p < 0.001). In addition, the mean CD8+ T-cell count was significantly different between the two groups: 30 per 0.025 cm2 (range 2–60) in the LTO group and 140 per 0.025 cm2 (range 23–314) in the patients without LTO (p < 0.01).
This study shows that patients who develop LTO after a local intervention have a higher M2/total TAM ratio and lower CD8+ cell count at diagnosis compared to patients who did not develop this outgrowth. We propose that the M2/total TAM ratio and the CD8+ T-cell amount are potential tools to predict which MPM patients are prone to develop LTO.
DIAGNOSTIC AND THERAPEUTIC ASPECTS IN MALIGNANT PLEURAL MESOTHELIOMA
2015, Revista Medica Clinica Las CondesPara el diagnóstico de mesotelioma se requiere distinguir entre afectación mesotelial benigna y maligna, y entre mesotelioma maligno y carcinoma metastásico. Para ello son necesarias técnicas inmuno-histoquímicas realizadas sobre biopsias amplias. La toracoscopia es la técnica de elección, aunque la biopsia con aguja usando técnicas de imagen en tiempo real puede ser muy útil si hay marcado engrosamiento nodular. Es improbable que la cirugía radical (pleuroneumonectomía) sea realmente curativa, por lo que está ganando adeptos la reducción de masa tumoral mediante pleurectomía/decorticación, con asociación de quimioterapia y radioterapia a la cirugía (terapia multimodal). Cuando la resección no es factible se plantea quimioterapia, con pleurodesis o colocación de un catéter pleural tunelizado si se requiere el control del derrame pleural y se reserva la radioterapia para tratar la infiltración de la pared torácica. También es esencial un completo control del dolor (que adquiere particular protagonismo en esta neoplasia) en unidades especializadas.
Diagnosis of malignant pleural mesothelioma requires making the distinction between benign mesothelial hiperplasia and true mesothelioma, and between malignant mesothelioma and metastatic pleural adenocarcinoma. This involves immunohisto-chemical techniques applied on large biopsy specimens, and thoracoscopy is the best choice for obtaining them. Real-time image-guided needle biopsy can also be very helpful in presence of marked nodular pleural thickening. Radical surgery (ie, extrapleural pneumonectomy) is unlikely to cure completely the patient, and cyto-reduction surgery with preservation of the underlying lung (pleurectomy/decortication), with addition of chemo and radiation therapy (muiltimodal treatment) is gaining adepts in the last few years. When surgery is not feasible at all, early chemotherapy -with pleurodesis or placement of a indwelling pleural catheter (to control the effusion if necessary)- is advisable. Radiation therapy should be reserved to treat chest wall infiltration in those cases, and complete control of pain in specialized units is also essential in those patients.
Uncommon Thoracic Tumors
2015, Clinical Radiation OncologyDiagnosis and Treatment of Malignant Pleural Mesothelioma
2015, Archivos de BronconeumologiaEl diagnóstico del mesotelioma pleural maligno presenta 3 importantes retos: es necesario distinguir entre hiperplasia mesotelial benigna y mesotelioma, entre mesotelioma maligno (con subtipos) y carcinoma metastásico, y también se requiere demostrar la invasión de estructuras vecinas a la pleura. Para aclarar los 2 primeros aspectos hay que basarse en un panel de anticuerpos monoclonales con adecuado estudio inmunohistoquímico —realizado por manos muy expertas— y para el tercero hay que apoyarse en biopsias suficientemente amplias y profundas, y la toracoscopia es la técnica de elección. La biopsia con aguja guiada con técnicas de imagen en tiempo real puede ser de gran ayuda cuando existe marcado engrosamiento nodular difuso y derrame pequeño o ausente. Dadas las dificultades de un diagnóstico precoz, es infrecuente que se consiga un tratamiento curativo mediante cirugía radical (pleuroneumonectomía), por lo que en los últimos años está ganando adeptos la liberación de masa tumoral mediante pleurectomía/decorticación, con asociación de quimio y radioterapia a las técnicas quirúrgicas (terapia multimodal). En los casos en que la cirugía no es factible se plantea la quimioterapia (combinando pemetrexed y compuestos de platino en la mayoría de los casos), con pleurodesis o colocación de un catéter pleural tunelizado si se requiere el control del derrame pleural, y se reserva la radioterapia para el tratamiento del dolor asociado a infiltración de la pared torácica o cualquier otra estructura vecina. En todo caso, es esencial un completo tratamiento de soporte para el control del dolor (que adquiere particular protagonismo en esta neoplasia) en unidades especializadas.
There are three major challenges in the diagnosis of malignant pleural mesothelioma: mesothelioma must be distinguished from benign mesothelial hyperplasia; malignant mesothelioma (and its subtypes) must be distinguished from metastatic carcinoma; and invasion of structures adjacent to the pleura must be demonstrated. The basis for clarifying the first two aspects is determination of a panel of monoclonal antibodies with appropriate immunohistochemical evaluation performed by highly qualified experts. Clarification of the third aspect requires sufficiently abundant, deep biopsy material, for which thoracoscopy is the technique of choice. Video-assisted needle biopsy with real-time imaging can be of great assistance when there is diffuse nodal thickening and scant or absent effusion. Given the difficulties of reaching an early diagnosis, cure is not generally achieved with radical surgery (pleuropneumonectomy), so liberation of the tumor mass with pleurectomy/decortication combined with chemo- or radiation therapy (multimodal treatment) has been gaining followers in recent years. In cases in which surgery is not feasible, chemotherapy (a combination of pemetrexed and platinum-derived compounds, in most cases) with pleurodesis or a tunneled pleural drainage catheter, if control of pleural effusion is required, can be considered. Radiation therapy is reserved for treatment of pain associated with infiltration of the chest wall or any other neighboring structure. In any case, comprehensive support treatment for pain control in specialist units is essential: this acquires particular significance in this type of malignancy.