Intensity-Modulated Radiotherapy After Extrapleural Pneumonectomy in the Combined- Modality Treatment of Malignant Pleural Mesothelioma Alexander Chi,

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Intensity-Modulated Radiotherapy After Extrapleural Pneumonectomy in the Combined- Modality Treatment of Malignant Pleural Mesothelioma Alexander Chi, MD, Zhongxing Liao, MD, Nam P. Nguyen, MD, Carol Howe, MD, Daniel Gomez, MD, Si Young Jang, PhD, Ritsuko Komaki, MD Journal of Thoracic Oncology Volume 6, Issue 6, Pages 1132-1141 (June 2011) DOI: 10.1097/JTO.0b013e3182199819 Copyright © 2011 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Axial, sagittal, and coronal images of a regular intensity-modulated radiotherapy treatment plan for malignant pleural mesothelioma after extrapleural pneumonectomy. The absolute dose levels in centigray (cGy) are listed on the upper left of each image from 500.0 to 6600.0 cGy, which equals to 5–66 Gy. The prescription dose of 45 Gy is well confined to the ipsilateral hemithorax (blue line) with the sparing of the heart and the spinal cord. Significant amount of the right lung is also spared of low dose (5 Gy) spread from the treated volume (light purple line). Journal of Thoracic Oncology 2011 6, 1132-1141DOI: (10.1097/JTO.0b013e3182199819) Copyright © 2011 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 These are the axial, coronal, and sagittal views of a treatment plan to deliver image-guided intensity-modulated radiotherapy through helical tomotherapy (HT) to treat a patient with malignant pleural mesothelioma of the left pleura, epithelioid type, pathological T4N2M0, stage IV after induction chemotherapy consisted of cisplatin and pemetrexed, and extrapleural pneumonectomy. The dose levels are represented by shades in different colors. The dose that each color represents is listed on the right side. The entire ipsilateral hemithorax was treated to 45 Gy in 25 fractions, which covered 99.2% of the planning target volume (PTV1), encompassing the entire hemithorax with margin. The area of high risk for microscopic residual disease was boosted to 60 Gy. This dose was delivered in a simultaneously integrated fashion in 25 fractions as well. The boost volume (red volume at the posterior-inferior left hemithorax as shown in the saggital view) was well covered by the 95% isodose (57 Gy) volume. The V5, V20, and MLD of the remaining lung were 30.2%, 5.2%, and 6.1 Gy, respectively. The patient had no acute or late pulmonary toxicity. Journal of Thoracic Oncology 2011 6, 1132-1141DOI: (10.1097/JTO.0b013e3182199819) Copyright © 2011 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 Algorithm for the definitive treatment of malignant pleural mesothelioma. Journal of Thoracic Oncology 2011 6, 1132-1141DOI: (10.1097/JTO.0b013e3182199819) Copyright © 2011 International Association for the Study of Lung Cancer Terms and Conditions