**10. Conclusion**

and to what degree these nodules impact on the quality of life of patients. To illustrate the confusion and debate surrounding the use of prophylactic irradiation, we need look no further than the evidence-based guidelines. The latest British Thoracic Society guideline continue to recommend prophylactic irradiation [190], whilst the European Society of Medical Oncology and the European Respiratory Society were not able to recommend it [191, 192]. In the penumbra of all this equipoise, a new randomised trial is being conduct‐ ed to assess the role of prophylactic irradiation in the modern era of chemotherapy, in an

Radiotherapy has been used both alone and as part of trimodality therapy in the radical treatment of MPM. A number of trials in the 1980's examined the use of radiotherapy alone with radical intent and found no survival benefit [194]. The use of radiotherapy for mesothe‐ lioma is complicated by the extensive field which it is required to covered, but at the same time juxtaposition of vital structures such as lung, oesophagus, spine, heart, liver and kidneys which limits the dose that can be delivered. Following irradiation of the hemithorax for mesothelio‐ ma, the loss of lung function is complete and equivalent to a pneumonectomy [195]. There is a real risk of treatment-related deaths, reaching 2 out of 12 in one retrospective series [196]. Because of this, it is felt radical radiotherapy should be delivered only after extrapleural pneumonectomy, to avoid the morbidity and mortality associated with life-threatening

The local relapse rate following surgery alone is 70-80% [105], and the focus of radiotherapy has shifted over the years to improving local control within the model of multimodality treatment. However, the rate of local recurrence from single modality radical treatment 53% [197], 35% [198] and 11% [199]. There is a suggestion of a dose-response relationship between radiation dosage and local recurrence but this has not yet been established [199] [200]. Beyond these observational series there is no randomised evidence yet to support or refute the use of postoperative radiotherapy. A multicentre randomised trial for radiotherapy within trimo‐ dality therapy is currently recruiting, but the trial will reach completion only in late 2017 [201]. At present, it is common to include postoperative hemithoracic irradiation to 54Gy within

With the tumour abutting a number of radiosensitive vital structures, there has been great interest in the use of intensity-modulated radiotherapy (IMRT) to deliver radiation in a field which conforms much more tightly to the target volume, in an effort to improve delivery to the tumour whilst reducing bystander irradiation. It is much more complex to deliver and requires significantly longer planning and treatment times. Whilst there is a growing body of evidence in support of the benefits of IMRT in various cancers, its use in mesothelioma appears to be harmful. In a series from Boston, fatal pneumonitis in the remaining lung occurred in 6 of 13 patients [202], whilst in MD Anderson, 23 of 63 patients died within 6 months of IMRT, of which 6 were from pulmonary causes [203]. The factor which predicted pulmonary complications appeared to be V20 (volume of lung receiving over 20Gy irradiation) [204]. At the same time, however, the locoregional failure rate remained at 13% [203]. Several subse‐

adequately powered multicentre study [193].

toxicity to the in-field ipsilateral lung.

trimodality therapy.

**9.2. Radical radiotherapy**

150 Principles and Practice of Cardiothoracic Surgery

In conclusion, MPM is an aggressive malignancy which presents insidiously, is difficult to diagnose and is resistant to most standard treatments. There have been a lot of developments over the years but the prognosis remains bleak. A number of ongoing current trials are looking to refine the treatment of this cancer, but it will probably take a quantum leap in thinking to really make a dent in the outcomes.

### **Author details**

Kelvin K.W. Lau and Calvin S.H. Ng

Department of Cardiothoracic Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China

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**Chapter 7**

**Recent Advances in Surgical Techniques for**

Christos Asteriou, Athanassios Kleontas and

Additional information is available at the end of the chapter

**Mesothelioma**

Nikolaos Barbetakis

**1. Introduction**

**2. Incidence**

http://dx.doi.org/10.5772/53397

**Multimodality Treatment of Malignant Pleural**

Malignant mesothelioma is a tumour which arises from mesothelial or possibly more primitive sub-mesothelialcells.Itoccursmostcommonlyinthepleura,butalsointheperitoneumandrarely in the pericardium or tunica vaginalis testis [1]. The vast majority of cases (almost 80%) arise from the pleural mesothelium, and of these, most (60-70%) are associated with asbestos exposure [2]. Thefirstclearevidenceofacausallinkbetweenasbestosexposureandprimarymalignanttumours of the mesothelium was the observation by Wagner et al. (1960) of 33 cases of pleural mesothelio‐ ma in the Northwest Cape Province of South Africa, 28 in individuals who had lived close to the crocidolite mines, mostly as children [3]. Subsequent studies, especially work by Selikoff and associates (1965) and Whitwell and Rawcliffe (1971) in the United States, confirmed that asbes‐ tos exposure was the major risk factor for malignant pleural mesothelioma [4–6]. The epidemiol‐ ogy of malignant pleural mesothelioma is now well understood, but its biological behavior

The incidence of malignant pleural mesothelioma was increasing and reached a peak in the years 2000-2005 in the United States, because of the large number of individuals who were exposed to asbestos during the 1930s to 1960s in asbestos mines and asbestos-related indus‐ tries, before the causal relationship between asbestos and malignant pleural mesothelioma was

and reproduction in any medium, provided the original work is properly cited.

© 2013 Asteriou et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

remains an enigma and the treatment of this cancer is still controversial.

