Malignant Pleural Mesothelioma: A Multi-Disciplinary Approach

Malignant pleural mesothelioma is a rare disease with poor prognosis. Surgery is used as a radical treatment modality but the risk of local relapse is very high. Therefore, radiation therapy is used in postoperative setting to improve local control. However, owing to elliptical shape, treating the entire pleura requires a large radiation field which increases toxicity. Precision radiation is mandatory to optimally irradiate the tumor area while sparing critical neighboring normal organs.

A 43-year-old male presented with history of right sided chest pain and cough for 8 months. On further evaluation, he was diagnosed with malignant pleural mesothelioma. The disease was localized but unresectable, therefore a course of neoadjuvant chemotherapy was given. Post chemotherapy, he underwent extra pleural pneumonectomy and the tumor was grossly excised. Histopathology revealed a close resection margin with metastasis in the regional lymph nodes. The case was discussed in multidisciplinary team meeting and adjuvant radiation therapy was offered. The patient was planned with a blend of modern intensity modulated radiation therapy technique and conventional three-dimensional conformal radiation therapy technique, to keep doses of adjacent organs within tolerance limits and at the same time deliver the intended dose of radiation to the tumor site.

Malignant pleural mesothelioma is a lethal disease. Orthodox methods of radiation delivery encompass the entire involved hemi thorax and result in significant morbidity. Highly conformal radiation techniques are preferred to achieve optimal therapeutic ratio at this site. However, despite advances in radiation techniques, current treatment modalities have not significantly made an impact on survival of these patients.