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In response to Dr. Komaki et al

      We would like to thank our colleagues at M.D. Anderson Cancer Center (MDACC) for sharing their insights and experiences in the treatment of thoracic malignancies with intensity-modulate radiation therapy (IMRT). As stated in our article, we believe that a critical factor in the fatal cases of pneumonitis seen in our series was the high level of low-dose radiation therapy to the lung, as measured by V5 (
      • Allen A.M.
      • Czerminska M.
      • Janne P.A.
      • et al.
      Fatal pneumonitis associated with intensity-modulated radiation therapy for mesothelioma.
      ). As we mentioned in our Discussion, the MDACC group had published data from esophageal cancer that indicated that volume spared 5 Gy is an important factor and should be considered in the evaluation of treatment plans for thoracic IMRT (
      • Wang S.L.
      • Liao Z.
      • Vaporciyan A.A.
      • et al.
      Investigation of clinical and dosimetric factors associated with postoperative pulmonary complications in esophageal cancer patients treated with concurrent chemoradiotherapy followed by surgery.
      ,
      • Lee H.K.
      • Vaporciyan A.A.
      • Cox J.D.
      • et al.
      Postoperative pulmonary complications after preoperative chemoradiation for esophageal carcinoma: Correlation with pulmonary dose-volume histogram parameters.
      ). Regarding the treatment of mesothelioma with IMRT after extrapleural pneumonectomy (EPP), we read with interest the information in the letter from MDACC concerning fatal pulmonary deaths. The 10% rate (7 of 63 patients) of fatal pulmonary deaths is of note. This corroborates our finding that IMRT after EPP should be approached with caution. It appears from the data presented in the letter that a mean lung dose (MLD) cutoff below 10.6 Gy and a V5 cutoff below 87% may be appropriate constraints. This is consistent with the MDACC recent publication of a new lung constraint of MLD <9.5 Gy (
      • Stevens C.W.
      • Rice D.
      • Forster K.
      • et al.
      IMRT after extrapleural pneumonectomy prevents local recurrence of mesothelioma.
      ), which we have recently adopted as well. We wholeheartedly agree with these new constraints and have devised a new technique for delivering post-EPP IMRT to 54 Gy, which meets the constraints of MLD <9.5 Gy and V5 <70% and will be presented at ASTRO 06 (
      • Czerminska M.A.
      • Hacker F.L.
      • Baldini E.H.
      • et al.
      ).
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      References

        • Allen A.M.
        • Czerminska M.
        • Janne P.A.
        • et al.
        Fatal pneumonitis associated with intensity-modulated radiation therapy for mesothelioma.
        Int J Radiat Oncol Biol Phys. 2006; 65: 640-645
        • Wang S.L.
        • Liao Z.
        • Vaporciyan A.A.
        • et al.
        Investigation of clinical and dosimetric factors associated with postoperative pulmonary complications in esophageal cancer patients treated with concurrent chemoradiotherapy followed by surgery.
        Int J Radiat Oncol Biol Phys. 2006; 64: 692-699
        • Lee H.K.
        • Vaporciyan A.A.
        • Cox J.D.
        • et al.
        Postoperative pulmonary complications after preoperative chemoradiation for esophageal carcinoma: Correlation with pulmonary dose-volume histogram parameters.
        Int J Radiat Oncol Biol Phys. 2003; 57: 1317-1322
        • Stevens C.W.
        • Rice D.
        • Forster K.
        • et al.
        IMRT after extrapleural pneumonectomy prevents local recurrence of mesothelioma.
        Lung Cancer. 2005; 49: s29
        • Czerminska M.A.
        • Hacker F.L.
        • Baldini E.H.
        • et al.
        Restricted field IMRT dramatically enhances IMRT planning for mesothelioma patients. American Society of Therapeutic Radiation Oncology, Philadelphia2006
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        • et al.
        Promising early local control of malignant pleural mesothelioma following postoperative intensity modulated radiotherapy (IMRT) to the chest.
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        • Ahamad A.
        • Stevens C.W.
        • Smythe W.R.
        • et al.
        Intensity-modulated radiation therapy: A novel approach to the management of malignant pleural mesothelioma.
        Int J Radiat Oncol Biol Phys. 2003; 55: 768-775
        • Forster K.M.
        • Smythe W.R.
        • Starkschall G.
        • et al.
        Intensity-modulated radiotherapy following extrapleural pneumonectomy for the treatment of malignant mesothelioma: Clinical implementation.
        Int J Radiat Oncol Biol Phys. 2003; 55: 606-616

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