Skip Navigation LinksHome > March 2014 - Volume 9 - Issue 3 > A Feasibility Study Evaluating Surgery for Mesothelioma Afte...
Journal of Thoracic Oncology:
doi: 10.1097/JTO.0000000000000078
Original Articles

A Feasibility Study Evaluating Surgery for Mesothelioma After Radiation Therapy: The “SMART” Approach for Resectable Malignant Pleural Mesothelioma

Cho, B. C. John MD*; Feld, Ron MD; Leighl, Natasha MD; Opitz, Isabelle MD; Anraku, Masaki MD; Tsao, Ming-Sound MD§; Hwang, David M. MD§; Hope, Andrew MD*; de Perrot, Marc MD

Free Access
Article Outline
Collapse Box

Author Information

Departments of *Radiation Oncology, Medical Oncology, and §Pathology, Division of Thoracic Surgery, Princess Margaret Cancer Centre and Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.

Disclosure: The authors declare no conflict of interest. Identifier: NCT00797719.

Presented at the 2013 American Society of Clinical Oncology (ASCO) Annual Meeting, Chicago, IL, May 31 to June 4, 2013.

Address for correspondence: Marc de Perrot, MD, Toronto Mesothelioma Research Program, Toronto General Hospital, 9N-961, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada. E-mail:

Collapse Box


Introduction: We developed an innovative approach for malignant pleural mesothelioma (MPM) with a short accelerated course of high-dose hemithoracic intensity-modulated radiation therapy (IMRT) followed by extrapleural pneumonectomy (EPP). This phase I/II study assessed the feasibility of Surgery for Mesothelioma After Radiation Therapy (SMART).

Methods: All resectable clinical T1-3N0M0 histologically proven, previously untreated MPMs were eligible. Patients received 25 Gy in five daily fractions during 1 week to the entire ipsilateral hemithorax with concomitant 5 Gy boost to areas at risk followed by EPP within 1 week of completing neoadjuvant IMRT. Adjuvant chemotherapy was offered to ypN2 patients on final pathologic findings. The primary end point was treatment-related mortality and secondary end points were overall survival, disease-free survival, treatment-related morbidity, and patterns of failure.

Results: Targeted accrual of 25 patients was completed between November 2008 and October 2012. All patients completed SMART. IMRT was well tolerated with no grade 3+ toxicities. EPP was performed 6 ± 2 days after completing IMRT without any perioperative mortality. Thirteen patients developed grade 3+ surgical complications. One patient (4%) died from treatment-related toxicity (empyema) during follow-up. All but one patient had stage III or IV disease on final pathologic findings. Five of 13 ypN2 patients received adjuvant chemotherapy. After a median follow-up of 23 months (range, 6–51), the cumulative 3-year survival reached 84% in epithelial subtypes compared with 13% in biphasic subtypes (p = 0.0002).

Conclusions: SMART is feasible in resectable MPM patients. This innovative protocol presents encouraging results and supports future studies looking at long-term outcome in patients with epithelial subtypes.

Industrialized countries are currently at the peak of an epidemic of malignant pleural mesothelioma (MPM).1 The incidence is expected to plateau by 2020 because asbestos has been banned for more than 30 years in most of these countries.2–4 However, the consumption of asbestos continues to increase in many areas of the world where its usage has not been regulated and could lead to a new surge of MPM in the near future.1

The overall prognosis of MPM is grim and treatment outcomes are disappointing. The median survival is 4 to 12 months without treatment and the 2-year overall survival is 0% to 12%.5–7 Various therapeutic approaches, from best supportive care to multimodal therapy, have been studied. The most aggressive therapy includes an extrapleural pneumonectomy (EPP) where the affected lung, pleural lining, diaphragm, pericardium, and areas of suspected involvement such as chest wall and lymph nodes are resected en bloc. The optimal treatment options for patients with resectable MPM remain controversial, but investigators at the most recent meeting from the International Mesothelioma Interest Group agreed that complete macroscopic surgical resection plays a vital role in the multimodality therapy of MPM, as is the case for other solid malignancies.8–10

In our experience, neoadjuvant chemotherapy followed by EPP and adjuvant hemithoracic intensity-modulated radiation therapy (IMRT) achieved a cumulative 3-year survival of 53% with a median survival of 59 months in patients with ypN0 disease who completed all three modalities.11 We and others observed that hemithoracic radiation was particularly successful to achieve local control after EPP.12–14 Unfortunately, the success of hemithoracic radiation is limited by distant failures, the most common sites being the abdominal peritoneal cavity and contralateral lung.11,13

A possible mechanism for this pattern of distant failure is inadvertent tumor spillage at time of EPP. If true, this suggests a possible theoretical advantage with neoadjuvant treatment designed to control the proliferative ability of clonogens spilt intraoperatively by means of tumoricidal and/or tumorostatic effects to prevent distant seeding. We, therefore, developed a new protocol with a short accelerated course of high-dose hypofractionated hemithoracic radiation followed by EPP in the hopes to improve radiation delivery and survival. We report the results of a seamless phase I/II study testing the safety and feasibility of Surgery for Mesothelioma After Radiation Therapy (SMART).

Back to Top | Article Outline


We conducted a two-step combined phase I/II prospective single cohort clinical feasibility study on surgically resectable MPM (Fig. 1). Eligible patients were at least 18 years of age, Eastern Cooperative Oncology Group performance status of 0 to 2, with good pulmonary function tests (defined as forced expiratory volume in 1 second >40% predicted or diffusing capacity of the lungs for carbon monoxide >45% predicted), a new histological diagnosis of MPM previously untreated, clinical stage T1-3N0M0, suitable for combined modality therapy, and able to give informed consent. Clinical stage was determined by computed tomography (CT) scan of the chest and abdomen, positron emission tomography (PET)-CT scan, and brain magnetic resonance imaging or CT. Preoperative nodal sampling with endobronchial ultrasound (EBUS) or mediastinoscopy was not routinely performed. The protocol was approved by our institutional review board. Written informed consent was obtained from each patient.

Figure 1
Figure 1
Image Tools

The clinical target volume is defined as the ipsilateral hemithorax, from the thoracic inlet down to the diaphragmatic insertion, including biopsy and drainage tract sites. The gross tumor volume is defined as any tumor seen on imaging (such as CT and PET). The dose prescription to the clinical target volume is 25 Gy in five daily fractions during approximately 1 week with a concomitant boost of 5 Gy to the gross tumor volume and tract sites. Typically, a multibeam IMRT technique is used. The complete details of IMRT will be published separately.

All patients underwent EPP within 1 week of completing the neoadjuvant IMRT. Surgery was completed according to a standard technique as previously described.11,15 EPP specimens were reviewed and reported by at least one subspecialty thoracic pathologist (M-ST or DMH). Histological diagnosis and staging were on the basis of the World Health Organization classification system and tumor, node, metastasis (TNM) staging system.16,17 Cases demonstrating mediastinal lymph node involvement (i.e., ypN2) were offered adjuvant chemotherapy, usually cisplatin and an antifolate, either raltitrexed or pemetrexed (as per the discretion of the medical oncologists), within 24 weeks after EPP.

After completing therapy, patients were followed every 4 weeks until 3 months; every 6 weeks until 6 months; every 2 months until 12 months; every 3 months until 2 years; and then every 6 months for 5 years. At each follow-up, a complete history, physical examination, and Eastern Cooperative Oncology Group performance status were recorded in addition to morbidity and mortality status. Routine tests included complete blood count, liver profile, creatinine, and chest radiograph. CT scan of the thorax and abdomen were done at 3, 6, 12, 18, and 24 months and then yearly afterward. Additional tests were done at the discretion of the oncologist. Recurrences were diagnosed clinically, usually by serial imaging and proven pathologically when feasible.

The study aim is to evaluate the feasibility of SMART. The primary end point is that the proportion of patients treated with grade 5 (G5) treatment–related mortality should not exceed 8%. The secondary aims are (1) to evaluate acute and late morbidity related to treatment; (2) to evaluate local recurrence, distant recurrence, disease-free survival, and overall survival rates; and (3) to identify factors and parameters associated with increased risk of treatment morbidity. Treatment-related toxicity was defined by the CTCAE v3.18

Back to Top | Article Outline

The initial pilot phase I study had a planned accrual of 12 patients. The risk of perioperative surgical mortality and morbidity (defined by 30-day or in-hospital grade 3–5 complications according to CTCAE v3) associated with EPP was anticipated to be 8% and 35%, respectively, on the basis of our previous experience.19 We assumed Bayesian posterior probability stopping rules with a sample size of 12, a priori probability of 0.08 for mortality (G5), and 0.35 for serious morbidity (G3+) with a confidence level of 0.95 that the (study) posterior probability was worse than the a priori probability.

On-going marginal posterior probability analysis with these assumptions gave the following stopping boundaries: if there were ≤1 treatment-related deaths (or ≤3 serious morbidity) in the first quartet of patients, then accrue second quartet; if there were ≤2 treatment-related deaths (or ≤5 serious morbidity) in total after the second quartet, then accrue third quartet (total of 12 patients). If there were ≤3 treatment-related deaths (or ≤7 serious morbidity) in the first 12 patients, we expanded to a phase 2 study and accrued an additional 13 patients (total of 25 patients) using the same protocol.

The analysis of the feasibility study was primarily descriptive. The proportion of patients treated without a major protocol violation as well as acute and long-term morbidity and mortality was collected. The cumulative rate of local and distant tumor recurrence was determined using the Kaplan–Meier method. The identification of factors associated with increased risk of treatment morbidity was determined by using the Student’s t test for continuous variables and either χ2 test or Fisher’s exact test for categorical variables. Variables tested were age, sex, side of tumor, histology, and stage of disease. Survival curves were compared using the log-rank test. Threshold for statistical significance was 0.05.

Back to Top | Article Outline


The accrual goal of 25 patients was completed between November 2008 and October 2012. Patient information is presented in Table 1. A total of 138 patients were seen during the same time frame and 82% were not eligible for the study because of advanced disease (n = 70), presence of comorbidities (n = 28), or patients’ refusal (n = 15). All 25 patients completed their intended IMRT and EPP. IMRT was well tolerated with no grade 3 to 5 toxicities (G3+). The most common grade 1 and 2 symptoms related to the IMRT were fatigue, nausea, and esophagitis. EPP was performed 6 ± 2 days after completion of IMRT. All but one patient had resection of the diaphragm and pericardium along with the parietal pleura and lung. In two patients, a chest wall resection of three ribs was required to achieve complete macroscopic resection.

Table 1
Table 1
Image Tools

Thirteen patients (52%) developed G3+ surgical complications (Table 2). The main G3+ complication was atrial fibrillation, occurring in five patients. No patients died within 30 days of surgery or during the postoperative hospital stay. One patient (4%) died from treatment-related complication (empyema) during follow-up at 88 days. Despite the preoperative radiation, no patient developed bronchopleural fistula immediately after surgery or during follow-up. The median length of stay after EPP was 12 days (range, 5–51 days). Age was the only factor potentially associated with increased risk of G3+ complications (66 ± 7 versus 60 ± 8 years in patients without G3+ complications; p = 0.06).

Table 2
Table 2
Image Tools

All but one patient were stage III (n = 11) or IV (n = 13) on final pathologic findings. One patient with biphasic histologic subtype had stage IB disease. Five of 13 patients (38%) with ypN2 disease underwent three to six cycles (median, 4 cycles) of adjuvant chemotherapy.

After a median follow-up of 23 months (range, 6–51 months), the cumulative overall survival reached 58% at 3 years (Fig. 2) The 3-year survival was significantly better for epithelial compared with biphasic histologic subtypes (Fig. 3). At 3 years, the cumulative survival reached 84% and disease-free survival 65% in patients with epithelial histologic subtype (Fig. 4). All patients with epithelial, ypT3 or ypT4, N2-negative disease were alive at last follow-up and only one (ypT4N0) developed recurrence.

Figure 2
Figure 2
Image Tools
Figure 3
Figure 3
Image Tools
Figure 4
Figure 4
Image Tools

Overall, 11 patients developed recurrence (7 biphasic and 4 epithelial subtypes). Recurrences were in the ipsilateral chest only (n = 2, 18%), ipsilateral chest and distant sites (n = 3, 27%), and distant sites only (n = 6, 55%). Distant sites of recurrences were located in the retro-peritoneal lymph nodes (n = 3), peritoneal cavity (n = 3), liver (n = 1), contralateral lung parenchyma (n = 4), and contralateral pleura (n = 1).

Back to Top | Article Outline


This study demonstrates for the first time that EPP after a short accelerated course of high-dose hemithoracic radiation is feasible. The radiation was extremely well tolerated with no grade 3+ toxicity and all patients proceeded to EPP within the predefined time frame with no perioperative mortality. Grade 3+ toxicity developed in 13 patients (52%) after surgery and included predominantly atrial fibrillation. We observed remarkably good outcomes in patients with epithelial histologic subtypes with a 3-year survival of 84% after a median follow-up of 23 months. At the last follow-up, only one of nine patients with epithelial N2-negative disease had developed recurrence despite the fact that all tumors were pathologic staged ypT3 and ypT4. Although longer follow-up and larger number of patients are required to make definitive conclusions on the long-term impact of this treatment protocol, these initial results are extremely encouraging for patients with epithelial MPM.

Nonepithelial histology was the most significant negative prognostic factors, confirming the findings of others.20,21 In this trial, most patients with biphasic tumor recurred within 18 months, suggesting that nonepithelial histology are likely not as radio-sensitive as epithelial subtypes to high-dose hypofractionated radiation. Hence, patients with biphasic disease should potentially be treated with a different approach than accelerated high-dose hemithoracic radiation and EPP.

Although the presence and the number and distribution of nodes are important predictors for survival, we elected not to perform systematic mediastinoscopy and/or EBUS in this initial phase I/II study.22 Mediastinoscopy and EBUS have a poor negative predictive value to rule out N2 disease and we thus decided not to exclude patients with potentially low-bulk N2 disease from this protocol as long as the CT and PET scan were negative for N2 disease.12,23 Furthermore, the impact of neoadjuvant IMRT on low-burden N2 disease was unknown and important to assess.

Despite the large number of right-sided EPP, which has been reported to be a risk factor for perioperative mortality,19,24 we observed only one treatment-related death after discharge from hospital in a patient with biphasic left-sided disease in this series of patients. Overall, our morbidity rate was similar to other surgical series with a 52% rate of grade 3 or 4 complications.24–26 Noteworthy, three patients developed venous thromboembolic event after discharged from hospital, and our protocol was therefore modified during the study to maintain patients on venous thromboembolic prophylaxis after discharged from hospital for at least a month.

The SMART protocol has several advantages related to the accelerated course of treatment. However, all patients must proceed to EPP after IMRT to avoid potential radiation-induced pulmonary toxicity. The protocol therefore requires a high degree of coordination and cooperation between radiation oncology and thoracic surgery. This may hamper its implementation in centers where multidisciplinary interest is lacking.

The therapeutic indication for SMART differs from standard induction protocols of radiation and chemoradiation because the short time course of radiation does not allow meaningful cytoreductive down staging. SMART aims to induce a tumorostatic and tumoricidal effect to prevent or delay the successful implantation of clonogens to distant sites at time of EPP and thereafter. In addition, increasing evidence suggest that the mechanisms of action of high-dose hypofractionated radiation differ from standard radiation in that the response is partly because of a specific activation of the immune system against the tumor rather than only a direct cytotoxic effect from the ionizing radiation.27,28 Hence, our protocol of high-dose radiation and surgery could provide a net benefit on the immune system by activating the immune system against the tumor and then removing the immunosuppressive environment generated by the tumor. The impact on the immune system of high-dose hypofractionated radiation therapy will potentially open the door for new combination therapies in the near future between immunotherapy and radiation to optimize their synergism on the immune system.28,29 This combined strategy will potentially be particularly valuable for patients with MPM.

Our study has several limitations related to the fact that this is a nonrandomized, single cohort phase I/II study. Hence, patient selection is a potential confounding factor. We note, however, that 18% of our patients were included into this trial during the 4-year period, which is similar to previously reported surgical series where typically 17% to 19% of patients screened in clinic are eligible for EPP.8,20 In addition, only one of 25 patients was found to have stage IB on final pathologic findings, suggesting that our population of patients had relatively advanced disease.

Normally, we would proceed to a phase 3 randomized trial but, as the Mesothelioma and Radical Surgery (MARS) trial showed, mounting such a study will likely be challenging and perhaps impossible.8 Most patients are reluctant to be randomized in a study with widely disparate treatment options. Although equipoise among the clinicians exist, patients often have strong treatment biases and may refuse randomization out right. MPM are rare tumors and these cases are technically challenging with a steep learning curve. Such cases are usually best handled by a dedicated radiation oncologist and thoracic surgeon to maintain volume of practice and retain technical expertise.

In conclusion, for the first time we have demonstrated that SMART is feasible in resectable MPM patients. Although larger number of patients and longer follow-up are required, this innovative protocol may potentially improve survival in selected epithelial MPM patients.

Back to Top | Article Outline


The authors thank Lea Dungao and Pat Merante for their assistance. This work has been supported by the Princess Margaret Hospital Foundation Mesothelioma Research Fund.

Back to Top | Article Outline


1. Stayner L, Welch LS, Lemen R. The worldwide pandemic of asbestos-related diseases. Annu Rev Public Health. 2013;34:205–216

2. Connelly RR, Spirtas R, Myers MH, et al. Demographic patterns for mesothelioma in the United States. J Natl Cancer Inst. 1987;78:1053–1060

3. Bianchi C, Giarelli L, Grandi G, et al. Latency periods in asbestos-related mesothelioma of the pleura. Eur J Cancer Prev. 1997;6:162–166

4. Peto J, Hodgson JT, Matthews FE, et al. Continuing increase in mesothelioma mortality in Britain. Lancet. 1995;345:535–539

5. Law MR, Hodson ME, Turner-Warwick M. Malignant mesothelioma of the pleura: clinical aspects and symptomatic treatment. Eur J Respir Dis. 1984;65:162–168

6. Ruffie P, Feld R, Minkin S, et al. Diffuse malignant mesothelioma of the pleura in Ontario and Quebec: a retrospective study of 332 patients. J Clin Oncol. 1989;7:1157–1168

7. Curran D, Sahmoud T, Therasse P, et al. Prognostic factors in patients with pleural mesothelioma: the European Organization for Research and Treatment of Cancer experience. J Clin Oncol. 1998;16:145–152

8. Treasure T, Lang-Lazdunski L, Waller D, et al.MARS Trialists. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol. 2011;12:763–772

9. Weder W, Stahel RA, Baas P, et al. The MARS feasibility trial: conclusions not supported by data. Lancet Oncol. 2011;12:1093–1094

10. Rusch V, Baldini EH, Bueno R, et al. The role of surgical cytoreduction in the treatment of malignant pleural mesothelioma: meeting summary of the International Mesothelioma Interest Group Congress, September 11–14, 2012, Boston, Mass. J Thorac Cardiovasc Surg. 2013;145:909–1110

11. de Perrot M, Feld R, Cho BC, et al. Trimodality therapy with induction chemotherapy followed by extrapleural pneumonectomy and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma. J Clin Oncol. 2009;27:1413–1418

12. de Perrot M, Uy K, Anraku M, et al. Impact of lymph node metastasis on outcome after extrapleural pneumonectomy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg. 2007;133:111–116

13. Rusch VW, Rosenzweig K, Venkatraman E, et al. A phase II trial of surgical resection and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma. J Thorac Cardiovasc Surg. 2001;122:788–795

14. Gomez DR, Hong DS, Allen PK, et al. Patterns of failure, toxicity, and survival after extrapleural pneumonectomy and hemithoracic intensity-modulated radiation therapy for malignant pleural mesothelioma. J Thorac Oncol. 2013;8:238–245

15. de Perrot M. Use of the posterior pericardium to cover the bronchial stump after right extrapleural pneumonectomy. Ann Thorac Surg. 2013;96:706–708

16. Travis WD, Brambilla E, Muller-Hermelink HK, Harris CC Tumours of the Lung, Pleura, Thymus and Heart. 2004 Lyon, France IARC Press

17. Rusch VW. A proposed new international TNM staging system for malignant pleural mesothelioma from the International Mesothelioma Interest Group. Lung Cancer. 1996;14:1–12

18. Trotti A, Colevas AD, Setser A, et al. CTCAE v3.0: development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol. 2003;13:176–181

19. de Perrot M, McRae K, Anraku M, et al. Risk factors for major complications after extrapleural pneumonectomy for malignant pleural mesothelioma. Ann Thorac Surg. 2008;85:1206–1210

20. Yan TD, Boyer M, Tin MM, et al. Extrapleural pneumonectomy for malignant pleural mesothelioma: outcomes of treatment and prognostic factors. J Thorac Cardiovasc Surg. 2009;138:619–624

21. Rusch VW, Giroux D, Kennedy C, et al.IASLC Staging Committee. Initial analysis of the international association for the study of lung cancer mesothelioma database. J Thorac Oncol. 2012;7:1631–1639

22. Flores RM, Routledge T, Seshan VE, et al. The impact of lymph node station on survival in 348 patients with surgically resected malignant pleural mesothelioma: implications for revision of the American Joint Committee on Cancer staging system. J Thorac Cardiovasc Surg. 2008;136:605–610

23. Rice DC, Steliga MA, Stewart J, et al. Endoscopic ultrasound-guided fine needle aspiration for staging of malignant pleural mesothelioma. Ann Thorac Surg. 2009;88:862–868

24. Stewart DJ, Martin-Ucar AE, Edwards JG, et al. Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations. Eur J Cardiothorac Surg. 2005;27:373–378

25. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg. 2004;128:138–146

26. Opitz I, Kestenholz P, Lardinois D, et al. Incidence and management of complications after neoadjuvant chemotherapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma. Eur J Cardiothorac Surg. 2006;29:579–584

27. Lee Y, Auh SL, Wang Y, et al. Therapeutic effects of ablative radiation on local tumor require CD8+ T cells: changing strategies for cancer treatment. Blood. 2009;114:589–595

28. Levy A, Chargari C, Cheminant M, et al. Radiation therapy and immunotherapy: implications for a combined cancer treatment. Crit Rev Oncol Hematol. 2013;85:278–287

29. Ludgate CM. Optimizing cancer treatments to induce an acute immune response: radiation Abscopal effects, PAMPs, and DAMPs. Clin Cancer Res. 2012;18:4522–4525

Mesothelioma; Neoadjuvant therapy; Hemithoracic radiotherapy; High-dose radiation; Accelerated radiation; Extrapleural pneumonectomy; Multimodality therapy

Copyright © 2014 by the European Lung Cancer Conference and the International Association for the Study of Lung Cancer.


Article Tools



Search for Similar Articles
You may search for similar articles that contain these same keywords or you may modify the keyword list to augment your search.

Other Ways to Connect



Visit on your smartphone. Scan this code (QR reader app required) with your phone and be taken directly to the site.

 For additional oncology content, visit LWW Oncology Journals on Facebook.