SMART: Surgery for Mesothelioma After Radiation Therapy

Quick Summary

SMART is a new and unconventional approach to mesothelioma treatment. It involves a standard surgical procedure for pleural mesothelioma called the extrapleural pneumonectomy, but combines it with high radiation therapy known as IMRT. SMART has so far shown promising results in preventing recurrence and increasing patient survival times.

What Is SMART?

Surgery for Mesothelioma After Radiation Therapy is also known as SMART. Developers of this treatment method approached it in a non-standard way, suggesting that the best way to combat mesothelioma is to use high-dose radiation therapy leading up to lung-removal surgery.

Essentially, this treatment method is a reversal of traditional cancer treatments when radiation is administered after surgery. Doctors have recently discovered that treating patients with radiation before surgery confines the disease to the lung and other infected areas. With the SMART approach, the microscopic mesothelioma cells that are usually left behind after surgery will be killed throughout the chest cavity. Killing off microscopic cells before surgery prevents seeding, which happens when mesothelioma cells move around during surgery and begin to multiply in distant sites.

Extrapleural Pneumonectomy for SMART Treatment

It must be noted that SMART can only be used with extrapleural pneumonectomy (EPP) surgery—removing the affected lung, the linings of the lung and heart and part of the diaphragm. The SMART approach delivers high levels of toxic radiation to the affected lung before surgery, meaning doctors must remove the radiated lung and its harmful toxins. The SMART treatment exposes the patient to extremely high doses of radiation, which is removed when the surgeons perform EPP.

How Does SMART Work?

The procedure for SMART follows a specific process. As the name suggested, first the patient undergoes radiation therapy followed by the extrapleural pneumonectomy procedure. The SMART approach can only be used on mesothelioma patients who have been approved for complete lung removal. It must also be noted that only those patients who have not yet been treated for mesothelioma are eligible for SMART treatment.

SMART approach is still being tested in clinical trials. In one study of 25 patients, the procedure consisted of a one-week period with patients being exposed to high-dose intensity-modulated radiation therapy (IMRT) before surgery. IMRT targets a single portion of the chest area and uses a computer controlled device called a linear accelerator.

This machine uses speed to ensure the radiation flows along a singular path, in order to limit damage to nearby healthy cells. The radiation is a light-induced therapy in which the beam exposes high doses of radiation in multiple short bursts. This sort of specialized radiation therapy has been discussed as a key component in treating mesothelioma.

Benefits of SMART for Mesothelioma

The SMART procedure was designed to target pleural mesothelioma tumors and affected surrounding areas, while mitigating damage to healthy tissues. High-dose radiation precisely targets cancerous tissue around the lung, leaving less chance of mesothelioma cells spreading to distant sites during the surgery that follows the radiation.

A 2017 study concluded that SMART involving the EPP procedures on pleural mesothelioma patients showed promising results. Experts have found that radiation therapy before EPP helps contain the tumor. Previous studies showed that administering radiation to patients after the extrapleural removal did not have any effect on the survival outcome to patients with mesothelioma. But administering radiation therapy before surgery using focused radiation is easier on the immune system. It also reduces the chances of recurrence after surgery, giving the patient a chance at longer survival.

Current and Ongoing Research Into SMART

SMART has been in constant evaluation over the years and has seen impressive outcomes in its clinical studies. Current and ongoing research into SMART include the four-year study from 2008-2012 conducted by Princess Margaret Cancer Centre and Toronto General Hospital. Thirteen of the 25 participating patients experienced surgical difficulties with one fatality.

The study conducted at Toronto General Hospital concluded that the SMART approach to pleural mesothelioma treatment resulted in a 3-year survival rate of 84% for patients with epithelioid subtype.

Epithelioid mesothelioma develops in the epithelial cells, which are tissues that line cavities, compose the glands and cover the body. Patients with epithelioid mesothelioma affecting experienced stronger results from SMART than those with biphasic (mixed) subtype mesothelioma, which only saw a 13% survival increase.

This study produced significant findings in the SMART approach. At the time of the study, the average survival rate for pleural mesothelioma was around 12 months, so a high 3-year survival rate is a massive improvement. Furthermore, according to the study, only half of the treated patients required additional chemotherapy after the EPP surgery.

Researchers believe the radiation-first procedure is imperative to preventing the spread of mesothelioma into the chest cavity. They are confident that SMART is a potential breakthrough in long-term treatment for mesothelioma patients.

SMART Side Effects

Treating mesothelioma patient with radiation typically puts them at risk of several uncomfortable side effects. These side effects vary from patient to patient and are also contingent on factors like where the cancer has formed, the patient’s age and other considerations. However, with SMART therapy targeting tumors so precisely, those who have undergone clinical trials have experienced far fewer symptoms than those using traditional radiation methods.

The following are common side effects associate with SMART therapy:

  • Fatigue within a few hours of radiation exposure, lessening slightly not too long after. Patients may also feel drained during the healing process within the second month after treatment.
  • Difficulty swallowing and coughing. Patients may also experience temporary shortness of breath.
  • Possible skin problems near the targeted area. The point at which the radiation beam was focused can cause radiation-induced irritation known as radiodermatitis. Typical responses to this exposure include skin rashes, swelling, or redness. There may also be some internal inflammation to the affected area, such as the lungs.

Seeking Mesothelioma Treatment With SMART

The SMART approach to pleural mesothelioma treatment has so far shown promising results for drastically increasing patient survival times. With its ground-breaking approach to treatment, SMART reduces the risk of local recurrence, allowing patients to live longer with a manageable condition. SMART remains one of the most prominent treatments in expanding research for mesothelioma.

Clinical trials for the SMART approach are currently underway and accepting new pleural mesothelioma patients. If you’re interested in the SMART approach to mesothelioma treatment or other multimodal therapies, contact our Patient Advocates today.

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Sources
  1. Thoracic. “A Feasibility Study Evaluating Surgery for Mesothelioma After Radiation Therapy “SMART” Approach for Resectable Malignant Pleural Mesothelioma”. Retrieved from: http://www.thoracic.org/members/assemblies/assemblies/thoracic-oncology/resources/JTO-SMART-2014-article-from-Peikert-2014.pdf. Accessed on January 17, 2018.
  2. Cancer Research UK. “A trial looking at radiotherapy to prevent spread of mesothelioma after a chest wall procedure (SMART trial).” Retrieved from: http://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-trial-looking-radiotherapy-prevent-spread-mesothelioma-after-chest-wall-operation-smart-trial#undefined. Accessed on January 17, 2018.
  3. NCBI. “A feasibility study evaluating Surgery for Mesothelioma After Radiation Therapy: the "SMART" approach for resectable malignant pleural mesothelioma.” Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/24445595. Accessed on January 17, 2018.

Last modified: May 7, 2018