Surgery for Mesothelioma: For Whom and When?
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A strong response from the Mount Sinai team to the perception created by MARS2 that surgery is harmful: surgical mortality (death rate) can fall as low as 0% in experienced centers and in the epithelioid subtype.
The Mount Sinai experience: a response to MARS2
Dr. Raja Flores and his team at Mount Sinai Hospital, one of the world's leading centers, published outcomes for patients operated on at their center during the same period as the MARS2 study (2015-2021).
The study included patients who underwent lung-sparing surgery known as pleurectomy/decortication (PD) , with 71 patients enrolled. More hazardous operations such as extrapleural pneumonectomy (complete removal of the lung together with its lining) were excluded in these patients.
Precision in patient selection
Patient selection criteria were emphasized as the key to success:
- Histology Matters: 79% of patients had the epithelioid subtype, which responds best to surgery. (Only 2.8% had the sarcomatoid type.)
- Comprehensive Staging: All patients (100%) underwent preoperative PET-CT and pulmonary function testing.
Results: a dramatic difference in safety
The high death rates observed in the surgical arm of MARS2 gave way to a safe outcome profile in this study.
Surgery: Not for Everyone, but Essential for the Right Patient
Removing surgery entirely from the mesothelioma treatment equation means throwing the baby out with the bathwater. This study reminds us that surgical success depends not only on the surgeon's manual skills but also on knowing who should not undergo surgery .
If a patient's tumor is of the epithelioid type, their general condition is good, and the operation will be performed at an experienced, high-volume center, surgery remains the strongest option for long-term survival. However, in aggressive tumors such as the sarcomatoid type, or in inexperienced hands, surgery may do more harm than good. Treatment decisions must be individualized and made in multidisciplinary tumor boards.
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