Pleurectomy/Decortication Safe & Effective for Mesothelioma with Careful Patient Selection | Annals of Thoracic Surgery Study

For patients diagnosed with pleural mesothelioma, a lung-sparing surgery called pleurectomy/decortication (P/D) can be a safe and effective treatment option when performed at experienced centers and tailored to the individual, according to a new study published in The Annals of Thoracic Surgery.

The research offers a counterpoint to concerns raised by the Mesothelioma and Radical Surgery 2 (MARS2) trial, a phase III study published in 2024 that suggested extended P/D was associated with worse survival and more adverse events compared to chemotherapy alone. The new findings emphasize that surgical outcomes are heavily influenced by careful patient selection and surgical technique.

“Our findings show that pleurectomy/decortication can be done safely when patients are carefully selected and surgery is tailored to balance tumor removal with the patient’s ability to tolerate aggressive treatment,” said Raja M. Flores, MD, Professor of Surgery at the Icahn School of Medicine at Mount Sinai and Chair of Thoracic Surgery for the Mount Sinai Health System. “This study highlights that outcomes depend not only on whether surgery is performed, but how and in whom.”

Understanding Pleural Mesothelioma and Surgical Options

Pleural mesothelioma is a rare and aggressive cancer that affects the lining of the lungs. Treatment options are limited, and historically, the standard surgical approach was extrapleural pneumonectomy (EPP), a more extensive procedure involving the removal of the entire lung, part of the diaphragm, and the parietal pleura. However, EPP carries a higher risk of complications and mortality.

P/D, in contrast, is a lung-sparing surgery that involves removing the pleura – the lining around the lungs – and any visible tumor. It aims to remove as much cancer as possible while preserving lung function. The debate over the role of surgery in mesothelioma treatment intensified following the MARS2 trial, prompting researchers to re-evaluate the effectiveness of P/D with a focus on optimizing patient selection and surgical technique.

Study Details and Key Findings

Dr. Flores and his team retrospectively analyzed data from 2015 to 2021 at Mount Sinai, focusing on patients who underwent P/D for pleural mesothelioma. They specifically excluded patients who underwent EPP to isolate the outcomes of the lung-sparing procedure. A total of seventy-one patients were included in the analysis.

The results demonstrated remarkably low mortality rates. The 30-day mortality rate was 0%, and the 90-day mortality rate was 4.2%. This is significantly lower than the 9% 90-day mortality rate reported in the MARS2 trial. The study authors attribute these favorable outcomes to a rigorous approach to patient selection and surgical planning.

The Importance of Patient Selection

The researchers found that the majority (78.9%) of patients in their cohort had the epithelioid subtype of pleural mesothelioma. This subtype is generally considered more responsive to treatment, including surgery. Conversely, only 2.8% of the patients had the sarcomatoid subtype, which tends to be more aggressive and less amenable to surgical resection.

Crucially, all patients underwent comprehensive preoperative testing to assess their overall health and suitability for surgery. This included modern imaging techniques and careful evaluation of their ability to tolerate the demands of the procedure. The researchers emphasize the importance of avoiding surgery in patients who are unlikely to benefit or who are at high risk of complications.

A Tailored Surgical Approach

Beyond patient selection, the study highlights the importance of a tailored surgical approach. The researchers advocate for maximal cytoreduction – removing as much tumor as possible – while carefully considering the patient’s tolerance for aggressive treatment. They also emphasize the need to avoid “seeding” cancer cells into the peritoneal or pericardial spaces during surgery, which could lead to recurrence.

Implications for Mesothelioma Treatment

The findings suggest that P/D should remain a consideration in the treatment of pleural mesothelioma, particularly for carefully selected patients at experienced centers. “This study reinforces that surgery should remain part of the conversation for mesothelioma treatment and can lead to long-term survivorship,” Dr. Flores stated.

The researchers believe that a multidisciplinary approach, combining surgery with other treatments such as chemotherapy and radiation therapy, is essential for optimal outcomes. They also emphasize the need for continued research to identify biomarkers and other factors that can help predict which patients are most likely to benefit from P/D.

“These results offer hope and clarity for patients facing a difficult diagnosis,” Dr. Flores added. “Surgery is not for everyone, but for the right patients, it can be both safe and meaningful.”