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Comment on "Effects of treatment regimens on survival in patients with malignant pleural mesothelioma".

We read with great interest the paper “Effects of treatment regimens on survival in patients with malignant pleural mesothelioma” by Abakay et al1. The treatment of mesothelioma remains difficult and most patients are treated without expection of cure; in this study, 266 patients, received only best supportive care. Instead, only 16 patients received a multimodality approach with surgery, chemotherapy and radiotherapy. This study confirms radiotherapy to be effective when used as part of a multimodality approach, when an extrapleural pneumonectomy was planned2. Mesothelioma cells, indeed, are not particularly radioresistant, therefore radiotherapy is biologically effective in tumor control; however, radiotherapy target is very close to radiosensitive structures. Despite there is no randomized clinical trial to support radiotherapy as adjuvant treatment, the best locoregional control is obtained in clinical trial adopting a multimodality treatment, as in other aggressive tumors3,4. Because of high local control of extrapleural pneumonectomy and radiotherapy, it is now possible to see a metastatizing mesothelioma5. That being so, the role of chemotherapy is not well defined and active regimens6 (cisplatin/gemcitabine and cisplatin/premetrexed) must lead to a reduction of disease diffusion in celom-derived membranes. To decrease mortality and morbidity associated to extrapleural pneumonectomy7, pleurectomy/decortication plus adjuvant chemotherapy and radiotherapy is been proposed. Luckraz et al8 reported 26 month median survival in 24 patients treated by pleurectomy/decortication, chemotherapy and radiotherapy. In this setting of patients, a radiotherapy with an high conformal dose distributionis necessary to increase effectiveness of treatment and decrease acute and late side effects sparing organs at risk. Ahamad et al9 demonstrated 100% in field local control in the first 45 patients. In palliative settings radiotherapy plays an important role to decrease size of tumor or severity of symptoms. It is demonstrated a equal result between palliation with radiotherapy and chemotherapy10; however, have all clinical trials testing chemotherapy (Treasur T Lancet Oncol 2011) offer radiotherapy to patients with painful disease and/or mechanical obstruction. In our institutes, radiotherapy is routinely offered to be tailored to the specific particular needs of each patient considering histological subtype, tumour stage and patient's individual functional assessment as well as comorbidity.