[The Successful Reduction of Resected Lung Volume for Intralobar Pulmonary Sequestration with Infrared Thoracoscope].

A 59-year-old male patient was referred to our hospital for further examinations and treatment due to an abnormal shadow detected in his left lower lung lobe on computed tomography. The patient was diagnosed with intralobar pulmonary sequestration and scheduled for an operation. During the surgery, after resection of the aberrant artery, indocyanine green was intravenously injected, and the border between normal lung and sequestrated lung was clearly identified by an infrared thoracoscope. Subsequently, wedge resection was performed, and the patient was discharged on postoperative day 5. Spirometry performed 6 months after the surgery indicated that the patient's lung function was well-preserved compared to the preoperative status.

[Successful Closure of Postpneumonectomy Bronchopleural Fistula with Inserting Technique of Omental Pedicle Flap into the Right Main Bronchus:Report of a Case].

A 67-year-old male was admitted to our hospital for the treatment of pyothorax due to bronchopleural fistula at right main bronchus after pneumonectomy for lung cancer( squamous cell carcinoma, pathological stageⅢB). After tube drainage and fenestration, we performed operation to close large diameter fistula, that was almost fully opened stump of the right main bronchus. Omental flap was sutured roughly to the fistula with four stiches and inserted into the bronchus lumen, and covered with latissimus dorsi muscle flap to fix omental pedicle flap and additionally performed thoracoplasty to close the residual space of the pleural cavity. Fistula at the stump became airtight after operation and pyothorax was cured, so our method was thought to be available to close large diameter bronchopleural fistula with omental pedicle flap.

Postoperative tegafur-uracil for stage I lung adenocarcinoma: first real-world data with an exploratory subgroup analysis.

PURPOSE: The effect of postoperative tegafur-uracil on overall survival (OS) after resection of stage I adenocarcinoma has been shown in clinical trials. The purpose of this study was to investigate whether findings from randomized trials of adjuvant tegafur-uracil are reproducible in a real-world setting. METHODS: A retrospective cohort study was performed using a multi-institutional database that included all patients who underwent complete resection of pathological stage I adenocarcinoma between 2014 and 2016. Survival outcomes for patients managed with and without tegafur-uracil were analyzed using the Kaplan-Meier method and a Cox proportional hazards model for the whole patient cohort and in a selected cohort based on eligibility criteria of a previous randomized trial. Propensity score matching was used to adjust for confounding effects. RESULTS: After propensity score matching, the hazard ratios for OS were 0.57 (95% confidence interval (CI) 0.29-1.14, P = 0.11) in the whole cohort and 0.69 (95% CI 0.32-1.50, P = 0.35) in the selected cohort. CONCLUSIONS: The effects of tegafur-uracil in this retrospective study appear to be consistent with those found in randomized clinical trials. These effects may be maximized in patients aged from 45 to 75 years.

[Metastases in the Lung and Mediastinal Lymph Nodes from Breast Cancer 28 Years after the First Operation:Report of a Case].

A 76-year-old woman was pointed out a small nodule in the right lower lung lobe on a chest computed tomography( CT) for follow-up examinations of malignant thyroid lymphoma. Although she had undergone a radical mastectomy for right breast cancer 28 years previously, the nodule was suspected to be either metastatic lymphoma or primary lung cancer and thoracoscopic surgery was planned to perform. Since the intraoperative frozen section diagnosis was adenocarcinoma, right lower lobectomy and systemic lymph node dissection were performed. However, the final pathology revealed that the lesion was breast cancer metastasis and subcarinal lymph nodes were also positive for metastases.

The C-reactive protein to albumin ratio is a prognostic factor for stage I non-small cell lung cancer in elderly patients: JACS1303.

PURPOSE: To establish the prognostic significance of C-reactive protein (CRP) and albumin in octogenarians with non-small cell lung cancer (NSCLC) based on the study of the Japanese Association for Chest Surgery (JACS 1303). METHODS: A total of 618 octogenarians with pathological stage I NSCLC, who underwent pulmonary resection, were included in the analysis. We conducted multivariable Cox regression analysis to evaluate the CRP to albumin ratio (CAR) as a potential prognostic factor. Other clinicopathological factors were also evaluated. RESULTS: The median age was 82 years. Operations included lobectomy (n = 388; 62.8%) segmentectomy (n = 95; 15%), and wedge resection (n = 135; 22%). Pathological stage IA was diagnosed in 380 (61.5%) patients. The 3-year (OS) and cancer-specific survival (CS) rates were 86.7% and 94.6%, respectively. OS was significantly higher for patients with low CAR (< 0.106) than for those with high CAR (≥ 0.106) (hazard ratio = 3.13, 95% confidence interval: 1.99-4.93, p < 0.0001). Univariate analysis identified sex, poor performance status, smoking status, comorbidity, solid tumor, histology, high Glasgow prognostic scale, and high CAR as significant prognostic factors. Multivariate analysis identified only the CAR as a significant prognostic factor for both OS and CS. CONCLUSIONS: Our analysis of the nationwide data demonstrated that the CAR is a useful prognostic factor for elderly patients with stage I NSCLC.

[Early Resuming of Continuous Ambulatory Peritoneal Dialysis on the Following Day After Surgery for Pleuroperitoneal Communication:Report of a Case].

A 72-year-old man was introduced continuous ambulatory peritoneal dialysis (CAPD) for chronic renal failure. Five months later, he was pointed out a massive right pleural effusion. Being diagnosed with pleuroperitoneal communication, he was referred to our department for surgery. Dialysis fluid and indocyanine green were injected through a peritoneal catheter for CAPD 30 minutes before surgery. A small fistula was detected by pressing the abdomen and using infrared thoracoscopy. The fistula was sutured and covered with polyglycolic acid sheet and fibrin glue. A day after surgery, CAPD was resumed. He was discharged on the post operative sixth day without any complications.

Survival of Octogenarians with Early-Stage Non-small Cell Lung Cancer is Comparable Between Wedge Resection and Lobectomy/Segmentectomy: JACS1303.

BACKGROUND: Anatomic resection with lymph node dissection or sampling is the standard treatment for early non-small cell lung cancer (NSCLC), and wedge resection is an option for compromised patients. This study aimed to determine whether wedge resection can provide comparable prognoses for elderly patients with NSCLC. METHODS: The study analyzed the clinicopathologic findings and surgical outcomes during a median follow-up period of 39.6 months for 156 patients with solid dominant (consolidation-to-tumor ratio > 0.5) small (whole tumor size ≤ 2 cm) NSCLC among 892 patients 80 years of age or older with medically operable lung cancer between April 2015 and December 2016. RESULTS: The 3-year overall survival (OS) rates after wedge resection and after segmentectomy plus lobectomy did not differ significantly (86.5 %; 95 % confidence interval [CI], 74.6-93.0 % vs 83.7 % 95 % CI, 74.0-90.0 %; P = 0.92). Multivariable Cox regression analysis of OS with propensity scores showed that the surgical procedure was not an independent prognostic predictor (hazard ratio [HR], 0.84; 95 % CI, 0.39-1.8; P = 0.64). The 3-year OS rates were slightly better after wedge resection for 97 patients who could tolerate lobectomy than after segmentectomy plus lobectomy (89.4 %; 95 % CI, 73.8-95.9 % vs 75.8 %; 95 % CI, 62.0-85.2 %; P = 0.14). The cumulative incidence of other causes for death was marginally higher after segmentectomy plus lobectomy than after wedge resection (P = 0.079). CONCLUSIONS: Wedge resection might be equivalent to lobectomy or segmentectomy for selected patients 80 years of age or older with early-stage NSCLC who can tolerate lobectomy.

Randomized phase II study of daily and alternate-day administration of S-1 for adjuvant chemotherapy in completely-resected stage I non-small cell lung cancer: results of the Setouchi Lung Cancer Group Study 1301.

BACKGROUND: The aim of this multicenter, randomized phase II study was to analyze the feasibility and safety of alternate-day S-1, an oral fluoropyrimidine, for adjuvant chemotherapy in patients with completely resected pathological stage I (tumor diameter > 2 cm) non-small cell lung cancer (NSCLC). METHODS: Patients were randomly assigned to receive adjuvant chemotherapy for 1 year comprising either alternate-day oral administration of S-1 (80 mg/m2/day) for 4 days a week (Group A) or a 2-week oral administration of S-1 (80 mg/m2/day) followed by 1 week of rest (Group B). The primary endpoint was feasibility, which was defined as the proportion of patients who completed the allocated intervention for 6 months with a relative dose intensity (RDI) of 70% or more. RESULTS: Ninety-three patients were enrolled of whom 90 patients received S-1 treatment. Median follow-up was 66.9 months. The treatment completion rate based on an RDI of 70% or more for 6 months was 84.4% (95%CI; 70.5-93.5%) in group A and 64.4% (95%CI; 48.8-78.1%) in group B. There were no grade 4 adverse events in either group. Moderate or severe adverse events (grade 2 or grade 3) were significantly more frequent in group B (67%) compared with group A (29%, P = 0.001). The 5-year relapse-free survival rate was 87.0 and 80.9% for group A and B, respectively (P = 0.451). The 5-year overall survival rate for all patients (n = 93) was 100 and 89.4% for group A and B, respectively (P = 0.136). CONCLUSION: Alternate-day oral administration of S-1 for 1 year as adjuvant chemotherapy was demonstrated to be feasible with low toxicity in completely resected stage I (tumor diameter > 2 cm) NSCLC. TRIAL REGISTRATION: Trial registration number: UMIN000011994 . Date of registration: 10/8/2013.

The treatment and survival of patients with postoperative recurrent thymic carcinoma and neuroendocrine carcinoma: a multicenter retrospective study.

PURPOSE: There are few data available on the outcomes of postoperative recurrent thymic carcinoma (TC) and thymic neuroendocrine carcinoma (TNEC). The aim of this study is to evaluate the treatment and survival in patients with recurrent TC and TNEC after undergoing surgical resection. METHODS: A retrospective chart review was performed using our multicenter database to identify patients with a postoperative recurrence of TC and TNEC from 1995 to 2018. The clinicopathological factors were reviewed and the survival outcomes were analyzed. RESULTS: Sixty patients were identified among 152 patients who underwent resection of TC and TNEC. The median follow-up period from the first recurrence was 14.8 months (range 0-144). The 5-year post-recurrence survival was 23% for the whole cohort. According to a univariable analysis, advanced stage [hazard ratio (HR) 2.81, 95% confidence interval (CI) 1.09-9.54], interval between primary surgery and recurrence (HR 0.97, 95% CI 0.95-0.99), any treatment for recurrence (HR: 0.27, 95% CI 0.13-0.58) and chemotherapy for recurrence (HR: 0.46, 95% CI 0.22-0.95) were significant factors related to post-recurrence survival. CONCLUSIONS: Chemotherapy rather than surgery appears to be the mainstay treatment for managing patients with postoperative recurrent TC and TNEC and it may also be considered in multidisciplinary management. Further studies with a larger sample size are required to confirm our findings.

[Surgery for Right Pulmonary Arteriovenous Malformation with Recurrent Brain Abscess:Report of a Case].

A 68-year-old man was referred to our hospital for further examination for chest abnormal shadow in the right lung field. He had a past history of subarachnoid hemorrhage. He was diagnosed with pulmonary arteriovenous malformation (PAVM) and recommended early treatment, but he didnot accept immediate surgical treatment. Three months later, he was transferred to other hospital emergently to treat nausea and dizziness. After being diagnosed with cerebellum abscess, external drainage was performed at our hospital. First drainage had a temporary efficacy, so second drainage was performed before referring to our department. Considering his condition and brain abscess, surgery for PAVM was done.

[Successful Negative Pressure Wound Therapy for Pleural Empyema by Closing Bronchopleural Fistula with Cyanoacrylate Products].

A 69-year-old man had experienced right upper lobectomy for inflammatory granuloma. Three months after surgery, he was diagnosed with pleural empyema due to bronchopleural fistula and open window thoracostomy was performed. Since we could not decrease the dead space and the amount of pleural effusion, we introduced negative pressure wound therapy (NPWT). Before applying, we closed the fistula with suturing and cyanoacrylate products. Four weeks later, we performed an operation to close the open window with muscle transposition. NPWT is reported to be useful to treat pleural empyema, but control the air leakage from fistulas is essential to introduce this treatment. We think cyanoacrylate products may be useful in closing fistulas temporarily to introduce NPWT.

Discohesive growth pattern (Disco-p) as an unfavorable prognostic factor in lung adenocarcinoma: an analysis of 1062 Japanese patients with resected lung adenocarcinoma.

Discohesive growth pattern (Disco-p) is often observed in lung adenocarcinoma (ADC) and mimics tumor budding (TB), stromal invasive-type micropapillary pattern (SMPP), and complex glandular pattern. However, the clinical impact of Disco-p in lung ADC has not been well studied. To investigate the prognostic significance of Disco-p, we analyzed 1062 Japanese patients with resected lung ADC. Disco-p was defined as an invasive growth pattern composed of single tumor cells, or trabeculae or small nests of tumor cells associated with desmoplastic fibrous stroma. We recorded the percentage of Disco-p in 5% increments independent of the major histologic pattern and investigated its correlation with different clinicopathological factors. We also analyzed the overall survival (OS) and disease-free survival (DFS). Disco-p was observed in 203 tumors (19.1%). Disco-p was significantly associated with male sex, smoking, lymph node metastasis, large tumor size, high TNM stage, lymphovascular and pleural invasion, spread through air spaces, and TB (all, p < 0.001). Of the total cases, only eight cases exhibited a dubious pattern between SMPP and Disco-p. Disco-p was also associated with wild-type EGFR (p < 0.001) and ALK fusion (p = 0.008). Patients harboring tumors with Disco-p had significantly worse prognoses (OS and DFS (both, p < 0.001)) compared with those without Disco-p. On multivariate analysis, Disco-p was an independent prognostic factor of worse OS (hazard ratio (HR), 2.572; 95% confidence interval (CI), 1.789-3.680; p < 0.001), and DFS (HR, 3.413; 95% CI, 2.482-4.683; p < 0.001), whereas TB was not an independent unfavorable prognostic factor. Disco-p was an independent unfavorable prognostic factor in patients with resected lung ADC, although a careful evaluation is necessary to distinguish it from similar patterns. We proposed that Disco-p should be recognized as a new invasive pattern and accurately recorded for the better management of patients with lung ADCs.

[Pulmonary Blastoma with the Differentiation of Adenocarcinoma and Large Cell Neuroendocrine Carcinoma in an Adult Patient;Report of a Case].

A 63-year-old man was pointed out a mass lesion in his chest X-ray at a medical checkup and referred to our hospital for further examination. Chest computed tomography showed a 4 cm-diameter tumor in the left upper lobe. He was diagnosed with adenocarcinoma by bronchoscopic biopsy. Therefore, we performed left upper lobectomy. The tumor was diagnosed as pulmonary blastoma with the differentiation of adenocarcinoma and large cell neuroendocrine carcinoma.

Survival outcomes after minimally invasive thymectomy for early-stage thymic carcinoma.

Minimally invasive surgery (MIS) has occasionally been used for selected patients with thymoma, but there is little information on the MIS approach for thymic carcinoma. The aim of this study was to evaluate survival outcomes after MIS for early-stage (Masaoka stage I-II) thymic carcinoma and thymic neuroendocrine carcinoma. A retrospective chart review of the cases recorded in our multi-institutional database was performed to identify patients who underwent resection for thymic carcinoma between 1995 and 2017. MIS thymectomy was performed in 17 cases (VATS, n = 14; RATS, n = 3. male, 41%; median age, 72 years). The median follow-up period was 32.7 (range 7.4-106) months. The five-year overall survival and relapse-free survival rates were 84.4% and 77.8%, respectively. The present study demonstrated encouraging preliminary results regarding MIS for the treatment of early-stage thymic carcinoma and thymic neuroendocrine carcinoma. Further studies with a larger sample size are required to evaluate the indications for this surgery.

[Segmentectomy for Congenital Left Upper Lobar Bronchial Atresia].

A 22-year-old woman visited a hospital to treat her dyspnea which had lasted for some months. Chest X-ray showed hyperlucency in her left upper lung field and chest computed tomography suggested left upper bronchial obstruction with mucoid impaction. She was referred to our hospital for further examination and treatment. Bronchoscopy showed left upper lobar bronchial atresia. Considering her dyspnea worsened in relatively short terms, surgical treatment was chosen and the resection of left upper division was successfully performed.

GATA6-positive lung adenocarcinomas are associated with invasive mucinous adenocarcinoma morphology, hepatocyte nuclear factor 4α expression, and KRAS mutations.

AIMS: GATA6 is known to play a role in lung development. However, its role in the carcinogenesis of lung cancer is not well studied. The aim of this study was to analyse GATA6 expression in lung adenocarcinomas (LAs) by immunohistochemistry (IHC) in order to define its association with clinicopathological characteristics. METHODS AND RESULTS: IHC analysis of GATA6 was performed with tissue microarray slides containing 348 LAs. The association between GATA6 expression and clinicopathological parameters was evaluated. GATA6 expression in epithelial tumours other than lung cancer was also evaluated. GATA6 expression was found in 47 LAs (13.5%). This occurred more frequently in younger patients (P = 0.005), and was associated with the absence of lymph node metastasis (P =0.024), well-differentiated to moderately differentiated tumours (P < 0.001), the absence of lymphatic invasion (P = 0.020), and the absence of vascular invasion (P = 0.011). GATA6 expression was associated with mucin production (P < 0.001), the invasive mucinous adenocarcinoma subtype (P < 0.001), KRAS mutations (P = 0.026), expression of MUC2 (P < 0.001), CDX2 (P = 0.049), and MUC5AC (P < 0.001), and absence of expression of TTF-1 (P = 0.002). GATA6 expression was also associated with hepatocyte nuclear factor 4α (HNF4α) expression (P < 0.001). GATA6 expression tended to indicate better prognoses, whereas patients with HNF4α expression had significantly worse prognoses (P = 0.033). Of 270 tumours other than lung cancer, 110 expressed GATA6. CONCLUSIONS: These findings suggest that GATA6 might interact with HNF4α and contribute to the development of mucinous-type LAs.

Adjuvant vinorelbine and cisplatin after complete resection of stage II and III non-small cell lung cancer: long-term follow-up of our study of Japanese patients.

PURPOSE: We reported previously a phase II study of adjuvant chemotherapy consisting of four cycles of vinorelbine (25 mg/m2) and cisplatin (40 mg/m2), given on days 1 and 8, every 4 weeks, to Japanese patients with completely resected stage II or III non-small cell lung cancer (NSCLC; UMIN 000005055). However, the follow-up was too short for us to evaluate a definitive 5-year overall survival rate and after-effects. METHODS: Between December 2006 and January 2011, 60 patients were enrolled in this study. We analyzed relapse-free and overall survival, long-lasting adverse effects, the influence of treatment on recurrent tumors, and the development of a second primary cancer, in relation with the regimen. RESULTS: After a median follow-up period of 95.8 months, the 5-year relapse-free and overall survival rates were 51.7 and 76.7%, respectively. Neuralgia developed in one patient and this was the only case of a long-lasting adverse effect. Recurrence developed in 31 patients, 29 of whom received intensive treatment. Although 16 s (or more) primary neoplasms developed among 13 patients, these were common carcinomas in Japan and did not include sarcoma or hematologic malignancies. CONCLUSION: Adjuvant vinorelbine and cisplatin chemotherapy showed encouraging relapse-free and overall survival rates, and long-term safety in Japanese patients with resected NSCLC.

Adipophilin expression in lung adenocarcinoma is associated with apocrine-like features and poor clinical prognosis: an immunohistochemical study of 328 cases.

AIMS: The lipogenic pathway is up-regulated in proliferating cells. However, the clinical impact of neoplastic steatogenesis in lung cancer is unclear. The aim of the present study was to evaluate the association of intracytoplasmic lipids with the clinicopathological features of lung adenocarcinoma (ADC), by immunohistochemical analysis of adipophilin (ADP), a coating protein found on intracytoplasmic lipid droplets. METHODS AND RESULTS: Tissue microarrays consisting of 328 primary lung ADCs surgically resected at Kyoto University Hospital were immunostained for ADP. Subsequently, correlations between ADP expression and clinical, molecular and survival data were performed. Fifty-one (15.5%) cases were ADP-positive. The presence of vascular invasion (P = 0.003), predominantly solid histology (P < 0.001), poorly differentiated type (P < 0.001), wild-type EGFR (P = 0.002), ALK fusion (P < 0.001), strong/diffuse mitochondrial staining (P < 0.001), a lack of surfactant protein B expression (P = 0.014) and a high Ki67 index (P < 0.001) were significantly correlated with ADP-positive ADC. In contrast, there were no correlations between ADP-positive ADC and sex, age, smoking history, tumour stage, thyroid transcription factor-1 expression, or KRAS mutational status. ADP-positive ADCs had apocrine-like features (P < 0.001). Patients with ADP-positive ADC had worse disease-free and overall survival (P = 0.047 and P = 0.013, respectively) than those with ADP-negative ADC. CONCLUSIONS: ADP was expressed in a small proportion of lung ADCs. ADP-positive lung ADC was significantly associated with apocrine-like features, wild-type EGFR, and poor prognosis, suggesting that ADP-positive lung ADC could be a distinct subtype of lung adenocarcinoma, induced by up-regulation of the lipogenic pathway.

Evaluating the effectiveness of RNA in-situ hybridization for detecting lung adenocarcinoma with anaplastic lymphoma kinase rearrangement.

AIMS: An easy and rapid assay for detecting mRNA in formalin-fixed paraffin-embedded samples [RNA in-situ hybridization (ISH)] has been reported recently. The aim of this study was to investigate the diagnostic accuracy of RNA ISH in detecting lung adenocarcinoma (LA) with anaplastic lymphoma kinase (ALK) gene rearrangement. METHODS AND RESULTS: We tested ALK RNA ISH on 11 resected LAs for which ALK fusion was confirmed by immunohistochemistry (IHC) and/or fluorescence in-situ hybridization (FISH). ALK mRNA expression was detected by RNA ISH in all 11 ALK-positive LAs, with a mean positive cell proportion of 68.4% (median, 75.3%; range, 3-98.8%), by counting 100 tumour cells at 10 different loci; RNA ISH did not detect ALK mRNA expression in the normal surrounding lung cells. Next, we explored the concordance between ALK RNA ISH and IHC/FISH tests by using tissue microarrays (TMAs) containing 294 LAs. In the TMA slides, we found five ALK-positive cases with IHC and/or FISH. The mean proportion of ALK RNA ISH-positive cells in these five cases was 75.6% (median, 82%; range, 40-94%), whereas the proportion of ALK RNA ISH-positive cells in the remaining 289 cases was 0.3% (median 0%; range, 0-15%). When the cutoff value was set at 15%, ALK RNA ISH-positive and ALK RNA ISH-negative cases were distinguishable with 100% sensitivity and specificity relative to the IHC/FISH tests. CONCLUSIONS: Our findings show that RNA ISH is useful for detecting ALK rearrangement with high sensitivity and specificity relative to conventional IHC/FISH tests. Thus, RNA ISH, which is an easy and rapid assay, could be an alternative method to IHC and FISH.

Long-term outcomes of intensity-modulated radiotherapy following extra-pleural pneumonectomy for malignant pleural mesothelioma.

BACKGROUND: The purpose was to evaluate safety and efficacy of intensity-modulated radiotherapy (IMRT) following extra-pleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM). MATERIAL AND METHODS: Patients with MPM of clinical stage I-III, which were macroscopic completely resected with EPP were eligible for this prospective study. The ipsilateral hemithorax was irradiated with a prescribed dose of 50.4 Gy. When the high-risk surgical margins or FDG-avid regions were identified, simultaneous integrated boost (SIB) with 56.0 Gy or 61.6 Gy was applied. RESULTS: Twenty-one patients were enrolled. SIB was applied to five patients. The planned IMRT fractions were completed in all, but four patients who suffered from severe fatigue or radiation pneumonitis. With a potential median follow-up of 6.3 years, overall survival was 37.5% at 3 years since the IMRT. The median survival time was 17.5 and 27.0 months since the IMRT and the initial treatment, respectively. Three patients have survived for more than 5 years. Distant metastasis was observed in 15 patients. Local recurrence was also observed in 2 of the 15 patients. Acute toxicities of Grade 3 or worse were observed in 15 patients, including 9 with hematological, 3 with pneumonitis and 6 with fatigue, nausea or vomiting. Five patients developed Grade 3 or worse late toxicities associated with IMRT, consisting of one with persistent Grade 4 thrombocytopenia, one with brain infarction and congestive liver dysfunction, and three with elevation of serum transaminase or biliary enzyme. No Grade 5 toxicity was observed. Patients with N2 showed significantly worse survival than those with N0-1 (18.2% vs. 60.0% at 3 years, p = .014). CONCLUSION: IMRT following EPP achieved excellent local control for MPM, that might lead to the long-term survival in selected patients. However, treatment burden including acute and late toxicities should be considered in this treatment approach.