Clinical case Pleural mesothelioma. Francesco Lucio

Transcription

1 Clinical case Pleural mesothelioma Francesco Lucio

2 Malignat Pleural Mesothelioma Mesothelioma is a rare malignant tumour originating from the cells lining the mesothelial surface of the coelomic cavities of the body. The background incidence of MPM is very low. Asbestos is the principal etiological agent of MPM. The first studies on the association between asbestos and MPM were published in the 1960s. Since most asbestos exposure is workrelated, mesothelioma is an occupational disease in the majority of cases J.P. van Meerbeeck et al. / Critical Reviews in Oncology/Hematology 78 (2011)

3 Consumo di amianto pro capite (Tonnnellate per milione di ab.) Numero annuale di decessi Consumo di amianto ( ) e decessi 1 per mesotelioma osservati 2 ( ) e previsti ( ) in Italia FABIO MONTANARO 1, ALESSANDRO MARINACCIO2 et al. Anno in cui l'amianto è stato proibito 1992 Anno anni* Atteso Stima 1 picco 2017: MM per anno Consumo procapite Ossevati Proiezione Media Mobile su 5 per. (Ossevati) Media Mobile su 5 per. (Consumo procapite) 1 Peto et al *Selikoff IARC Scientific Publication 1 Uomini, anni Stimati: decessi per tumore pleurico * 0.73

4 Terapia dei Mesoteliomi Nessuna terapia (supporto) Radioterapia esclusiva Pleurectomia/Decorticazion e P/D + RT postoperatoria PleuroPneumonEctomia/PP E PPE + RT postoperatoria +/- CT + + +

5 Radiotherapy in MPM Palliative radiotherapy: for palliation of symptoms for patients with advanced disease As for other palliative indications,hypofractionation with 4G fractions is currently advocated, for a total dose bio-equivalence of Gy. Prophylactic radiotherapy to reduce recurrences at sites of diagnostic or therapeutic instrument insertion irradiation with a 7 Gray (Gy) fractionation for three consecutive days, in the four weeks Postoperative/Radical Treatment RT as part of multimodal definitive treatment to improve locoregional control after resection of early stage disease total dose more than 54 Gy to the hemithorax. The use of radiation therapy to the full hemithorax is limited by critical organs (lung, liver, heart, spinal cord, esophagus and Kidney).

6 Radiotherapy ESOPHAGUS CONTROLATERAL LUNG CONTROLATERAL KIDNEY STOMACH PTV IPSLATERAL KIDNEY SPINE Large irregularly shaped area at risk Proximity of critical structures

7 3D CRT Moderate dose radiotherapy MDRT AP/PA 30 Gy The mediastinum was treated to an additional 10 Gy for a cumulative dose of 40 Gy. A. M. ALLEN et al.2007

8 3D CRT High Dose RT A. M. ALLEN et al.2007 AP/PA 39.6 Gy Abdominal block to shield kifney and partial liver- area treat with electrons. AP/PA off cord to block spine and mediastinum. Heart block eventually for left lung Boost 14.4 Gy e - e-

9 ADJUVANT MALIGNANT MESOTHELIOMA RADIOTHERAPY: HOW MANY DIFFICULTIES! Russi, Lucio et al IJROBP 2006

10 3D CRT moderate vs high radiotherapy A. M. ALLEN et al.2007 It suggested that a greater radiation dose and a larger volume to include the entire hemithorax and adjacent areas could perhaps reduce the locoregional failure rate

11 Quale Bersaglio? 65% P/D Flores 11% 30% EPP 22% 21% P/D Pleurectomia/decortica zione [P/D] rimuove la pleura e il mesotelioma senza rimuovere il polmone. 39% EPP PleuroPneumonEctomia rimozione di: Polmone Pleura parietale e viscerale Diaframma Pericardio Flores 08

12 3D CRT vs IMRT PTV1 45Gy PTV Gy KRAYENBUEHL et al, Int. J. Radiation Oncology Biol. Phys., Vol. 69, No. 5, pp , 2007

13 3D CRT vs IMRT IMRT seems to be the superior technique to deliver greater doses with better dose homogeneity, even though the larger doses to the OARs, especially in the contralateral lung, must be taken into consideration KRAYENBUEHL et al, Int. J. Radiation Oncology Biol. Phys., Vol. 69, No. 5, pp , 2007

14 IMRT vs tomotherapy Target homogeneity and coverage could be significantly improved with tomotherapy

15 IMRT vs tomotherapy slight advantages in normal tissue sparing

16 IMRT vs RA RA demonstrated similar target coverage and better dose sparing to the OARs compared with fixed-gantry IMRT. The time required to deliver the dose was much lower M. SCORSETTI et al. 2010

17 WARNING Fatal Radiation Pneumonitis Conventional RT N of pts % of Fatal RP Toronto General Hospital 29 0% University of Padua 15 0% MSKCC 54 0% BWH 183 0% IMRT N of pts % of Fatal RP Allen, BWH % NKI, Denmark % Miles, Duke % Rice, MDACC % Gupta et al. 2009

18 WARNING New DVH for controlateral lung Study DVHs for controlateral lung MLD V20 Allen, BWH 06 > 13 Gy > 15% Miles, Duke 08 > 11 Gy > 7% Rice, MDACC 07 > 8.5 Gy > 7% most frequent side effects ipsilateral kidney is largely included in the radiation field, contralateral kidney should in fact contribute to the entire renal perfusion

19 Clinical Case Patient Profile Uomo 30/1/51 59 anni Esposizione professionale all amianto 25/5/2010 biopsia pleurica 22/6/2010 chirurgia mediastino scopia cervicale 6/7/10 pleuropneumectomia istologico pt1bpn0

20 IMRT 11/11/2010 inizio PORT 1.8 Gy x 27 sed = 48.6Gy S&S 7 beams 83 segments 46 Gy

21 CI95=0.16 HImax=1.16 DVH D98=44.7Gy D50=48.5Gy V5=30% MLD =5Gy V20=2.5% D2=51.8Gy

22 Pre-treatment dosimetry Gamma(4% 3mm)= 96.5% Omnipro with EBT in CIRS phantom

23 PET CT 8/6/ Captazione pleurica 2012

24 Conclusion

25 Conclusion The most appropriate timing should be discussed upfront in a multidisciplinary board, including radiation oncologists. Dose of radiation for adjuvant treatment following EPP should be Gy in Gy daily fractions, with 60 Gy delivered to macroscopic residual tumors if any. IMRT is a promising treatment technique reduce radiation exposure of the remaining lung, as the risk of fatal pneumonitis with IMRT (V20 < 10%; mean lung dose preferably <8.5 Gy; low dose volumes minimized, with V5 < 60%).