Lung-Sparing Surgery Offers Hope for Mesothelioma Patients

A new study strengthens evidence supporting lung-sparing surgery for pleural mesothelioma, offering a potentially safer and equally effective alternative to more aggressive procedures. Researchers at Mount Sinai found that carefully selected patients undergoing pleurectomy/decortication experienced significantly lower mortality rates compared to those in a landmark clinical trial.

Understanding Pleurectomy/Decortication

Pleurectomy/decortication is a surgical procedure to remove the lining of the lung (pleura) and any visible tumor. It aims to remove as much of the cancer as possible while preserving lung function. This contrasts with extrapleural pneumonectomy (EPP), which involves removing the entire lung, a portion of the diaphragm and the pericardium.

The MARS2 Trial and Subsequent Research

The initial findings from the Mesothelioma and Radical Surgery 2 (MARS2) trial raised concerns about the effectiveness of extended pleurectomy/decortication, suggesting higher early mortality and questioning its value compared to chemotherapy alone. Mount Sinai researchers revisited these findings, focusing on surgical outcomes during the same period as the MARS2 trial (2015-2021).

Mount Sinai Study Findings

The Mount Sinai study, published in The Annals of Thoracic Surgery, analyzed outcomes for 71 patients undergoing pleurectomy/decortication. The results were encouraging:

• 30-day mortality rate: 0%
• 90-day mortality rate: 4.2%

This compares favorably to the 9% 90-day mortality rate observed in the MARS2 trial. Dr. Raja M. Flores, lead author of the study and Professor of Surgery at the Icahn School of Medicine at Mount Sinai, emphasized that outcomes depend on both whether surgery is performed and how it is performed, and in whom.

Patient Selection and Surgical Approach

The study highlighted the importance of careful patient selection and a tailored surgical approach. Key factors included:

• Epithelioid subtype: Patients with the epithelioid subtype of mesothelioma (78.9% in the Mount Sinai group) tend to respond better to surgery.
• Sarcomatoid histology: Patients with the sarcomatoid subtype (2.8% in the Mount Sinai group) generally do not respond as well.
• Rigorous testing: All patients underwent comprehensive testing before surgery.
• Maximal cytoreduction: Researchers suggested maximizing tumor removal while avoiding damage to surrounding tissues.

The Role of Multidisciplinary Care

Malignant pleural mesothelioma requires a multidisciplinary approach involving chemotherapy, radiation, immunotherapy, and surgery. Research indicates that surgery remains a foundational element of treatment, aiming to remove macroscopic disease. Preserving lung tissue through pleurectomy/decortication may be preferable to EPP.

Looking Ahead

“These results offer hope and clarity for patients facing a difficult diagnosis,” said Dr. Flores. “Surgery is not for everyone, but for the right patients, it can be both safe and meaningful.” The study reinforces that surgery should remain a consideration in the treatment of mesothelioma, particularly at experienced, high-volume centers.