Extra-pleural pneumonectomy in the era of image-guided intensity-modulated radiotherapy

  • Marco Trovo
  • Davide Franceschini
  • Carlo Furlan
  • Francesca Pietrobon
  • Stefano Vagge
  • Eleonora Farina
  • Alberto Revelant
  • Luca Visani
  • Virginia Maragna
  • Giuseppe ParisiEmail author
  • Vieri Scotti



To assess the outcome of malignant pleural mesothelioma patients treated with extra-pleural pneumonectomy (EPP) and adjuvant radiotherapy (RT), using the most advanced radiotherapeutic techniques, namely image-guided intensity-modulated RT (IG-IMRT).

Methods and materials

Fifty-four patients were analyzed. Minimum radiation dose was 50 Gy (2 Gy/fr). Planning target volume encompassed the entire hemithorax, including the ipsilateral mediastinum if interested by disease, the pericardium and diaphragm, and any drain sites. The study endpoints included loco-regional control (LRC), distant metastases free survival (DMFS), and overall survival (OS), as well as radiation-related toxicity.


Major patients and treatment characteristics were the following: median age 62 years, epithelioid histology in 51 (94%) cases, locally advanced disease in 41 (90%) cases, and metastatic mediastinal lymph nodes in 27 patients (50%). Only 7 patients (13%) had gross residual disease after surgery. Chemotherapy was administered in 38 patients (70%). Median follow-up was 16 months (range 0–73 months). Median and 2-year OS were 21 months and was 43.8%, respectively. The predominant pattern of failure was distant: 34 patients (62.9%) developed some component of distant failure, and only 5 patients (9.2%) developed an isolated loco-regional recurrence. The estimates of LRC and DMFS at 2 years were 63.4% and 43.4%, respectively. Three fatal pneumonitis were documented. Other major toxicities included: Grade 2 and 3 pneumonitis in 1 and 2 cases, respectively, 1 case of bronchial fistula, pleural empyema, and Grade 3 esophagitis, respectively.


Although executed in the era of high-technology radiotherapy (IG-IMRT), EPP should not be routinely performed.


Malignant pleural mesothelioma Image-guided IMRT Extra-pleural pneumonectomy 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Italian Society of Medical Radiology 2019

Authors and Affiliations

  • Marco Trovo
    • 1
  • Davide Franceschini
    • 2
  • Carlo Furlan
    • 3
  • Francesca Pietrobon
    • 3
  • Stefano Vagge
    • 4
  • Eleonora Farina
    • 5
  • Alberto Revelant
    • 5
  • Luca Visani
    • 6
  • Virginia Maragna
    • 6
  • Giuseppe Parisi
    • 1
    Email author
  • Vieri Scotti
    • 6
  1. 1.Department of Radiation OncologyAzienda Sanitaria Universitaria Integrata UdineUdineItaly
  2. 2.Department of Radiotherapy and RadiosurgeryHumanitas Cancer Center and Research Hospital, RozzanoRozzanoItaly
  3. 3.Department of Radiation OncologyOspedale San Martino di BellunoBellunoItaly
  4. 4.Department of Radiation OncologyAzienda Ospedaliera Universitaria San Martino di Genova - IST, Istituto Nazionale Ricerca sul CancroGenoaItaly
  5. 5.Radiation Oncology DepartmentNational Cancer Institute, CRO IRCCSAvianoItaly
  6. 6.Department of Radiation OncologyAzienda Ospedaliero Universitaria Careggi, University of FlorenceFlorenceItaly

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