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Purpose of Review <p>This review examines the evolution of surgical strategies for pleural mesothelioma (PM) over the past decade, focusing on the paradigm shift from aggressive extrapleural pneumonectomy to lung-sparing approaches. We sought to evaluate how randomized trial evidence, contemporary databases, and advances in systemic therapy have reshaped surgical decision-making and patient selection algorithms.</p> Recent Findings <p>The MARS and MARS 2 randomized trials challenged traditional surgical approaches, with MARS 2 reporting worse outcomes with extended pleurectomy/decortication (EPD) compared to chemotherapy alone, though serious concerns about methodology, surgical quality assurance and analysis were persist. National database analyses consistently show lower mortality with lung-sparing procedures compared to extrapleural pneumonectomy. Histologic subtype has emerged as a critical selection criterion, with surgery showing benefit primarily in epithelioid disease. Biomarkers such as Ki67 expression and mesothelin provide additional prognostic stratification. The CheckMate 743 trial established immunotherapy combinations as suitable care for unresectable disease, prompting investigation of neoadjuvant immunotherapy approaches.</p> Summary <p>Summary: Surgery for pleural mesothelioma has evolved from extrapleural pneumonectomy to selective, lung-preserving strategies within multimodality care. Patient selection emphasises epithelioid histology, favourable biomarker profiles, and treatment in high-volume specialist centers. The integration of immunotherapy and development of predictive biomarkers will likely further refine surgical candidacy, making personalised treatment algorithms the future standard of care.</p>

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A Decade of Progress: Evolving Surgical Strategies for the Treatment of Pleural Mesothelioma

  • 期刊论文

  • 发表日期：

    2026年7月1日

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  • Kudzayi H. Kutywayo,
  • Alan G. Dawson,
  • Karishma Chandarana,
  • Dean A. Fennell,
  • Edward J. Caruana,
  • Apostolos Nakas

摘要

Purpose of Review

This review examines the evolution of surgical strategies for pleural mesothelioma (PM) over the past decade, focusing on the paradigm shift from aggressive extrapleural pneumonectomy to lung-sparing approaches. We sought to evaluate how randomized trial evidence, contemporary databases, and advances in systemic therapy have reshaped surgical decision-making and patient selection algorithms.

Recent Findings

The MARS and MARS 2 randomized trials challenged traditional surgical approaches, with MARS 2 reporting worse outcomes with extended pleurectomy/decortication (EPD) compared to chemotherapy alone, though serious concerns about methodology, surgical quality assurance and analysis were persist. National database analyses consistently show lower mortality with lung-sparing procedures compared to extrapleural pneumonectomy. Histologic subtype has emerged as a critical selection criterion, with surgery showing benefit primarily in epithelioid disease. Biomarkers such as Ki67 expression and mesothelin provide additional prognostic stratification. The CheckMate 743 trial established immunotherapy combinations as suitable care for unresectable disease, prompting investigation of neoadjuvant immunotherapy approaches.

Summary

Summary: Surgery for pleural mesothelioma has evolved from extrapleural pneumonectomy to selective, lung-preserving strategies within multimodality care. Patient selection emphasises epithelioid histology, favourable biomarker profiles, and treatment in high-volume specialist centers. The integration of immunotherapy and development of predictive biomarkers will likely further refine surgical candidacy, making personalised treatment algorithms the future standard of care.