Computed tomography features of local pleural recurrence in patients with malignant pleural mesothelioma treated with intensity-modulated pleural radiation therapy

  • Darragh HalpennyEmail author
  • Micheal Raj
  • Andreas Rimner
  • Junting Zheng
  • Marinela Capanu
  • Michelle S. Ginsberg



This study was conducted in order to describe the computed tomography (CT) features of local pleural recurrence in patients with malignant pleural mesothelioma undergoing intensity-modulated pleural radiation therapy (IMPRINT) as part of multimodality treatment.


In this observational study, 58 patients treated with IMPRINT between September 21, 2004, and December 1, 2014 were included. Baseline and follow-up CT scans were qualitatively assessed. On follow-up scans, pleural thickening was categorized as unchanged, decreased, or new/increased. New/increased pleural abnormality was subcategorized as diffuse smooth pleural thickening, diffuse nodular pleural thickening, focal pleural nodule, or multiple pleural nodules. To identify features more frequently present at the time of local recurrence, follow-up scans with local recurrence were matched to four control scans; exact conditional logistic regression was performed.


Twenty-one (36%) patients had local pleural recurrence and 20 (34%) patients had nonpleural recurrence; 3 patients had both types of recurrence. The 1-year cumulative incidence rate of local recurrence was 27% (95% confidence interval 15, 39). On follow-up scans, three patterns of pleural abnormality were significantly associated with local recurrence: new/increased multiple pleural nodules (10 (48%) positive scans vs 0 control scans), new/increased diffuse nodular pleural thickening (7 (33%) positive scans vs 1 (1%) control scans), and new/increased focal pleural nodule (3 (14%) positive scans vs 1 (1%) control scan) (p < 0.001 for all).


Multiple new/increased pleural nodules are the feature most commonly present at local recurrence following IMPRINT; however, any pattern of increased nodular pleural thickening is suspicious.

Key Points

• In patients with mesothelioma receiving intensity-modulated pleural radiation as part of multimodality therapy, increasing multiple pleural nodules is the computed tomography feature most commonly present at local recurrence.

• In these patients, any CT pattern of increased nodular pleural thickening should be considered suspicious for local recurrence.

• The most common sites of nonpleural recurrence were lung parenchyma, thoracic lymph nodes, and peritoneum.


Malignant mesothelioma Intensity-modulated radiotherapy Local neoplasm recurrence X-ray computed tomography Pleura 



Cumulative incidence rate


Computed tomography




Intensity-modulated pleural radiation therapy


Interquartile range


Malignant pleural mesothelioma


Modified response evaluation criteria in solid tumors


Magnetic resonance imaging


Picture archiving and communications system


Positron emission tomography



This research was funded in part through the National Institute of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Michelle Ginsberg.

Conflict of interest

The authors of this manuscript declare relationships with the following companies: Merck (Andreas Rimner, not relevant to the submitted work), AstraZeneca (Andreas Rimner, not relevant to the submitted work), and Varian Medical Systems (Andreas Rimner, not relevant to the submitted work).

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• observational

• performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Darragh Halpenny
    • 1
    Email author
  • Micheal Raj
    • 1
    • 2
  • Andreas Rimner
    • 3
  • Junting Zheng
    • 4
  • Marinela Capanu
    • 4
  • Michelle S. Ginsberg
    • 1
  1. 1.Department of RadiologyMemorial Sloan Kettering Cancer CenterNew YorkUSA
  2. 2.Department of RadiologyLong Island Jewish Medical CenterNew Hyde ParkUSA
  3. 3.Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkUSA
  4. 4.Department of BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkUSA

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