Surgery for mesothelioma: the evidence base and a pragmatic approach to surgical treatment

  • Vasudev Baburaya Pai
  • Kandadai Seshadri Rammohan
  • Tom TreasureEmail author
Review Article


The authors were invited to provide a summary of the current evidence and an evidence-based approach to practice. Clinical practice guidelines are not available for India and a formal approach to these would require a properly constituted guideline development group rather than an opinion piece from three surgeons. What we have provided is a critical view of current practice and some pointers to a realistic pragmatic approach intended to avoid non-evidence-based practice and excessive harm to no advantage.


Malignant mesothelioma Surgical management Surgery 


Compliance with ethical standards

There is no research reported in this paper.

We only summarise and review clinical work already completed and published.

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    van Zandwijk N, Clarke C, Henderson D, et al. Guidelines for the diagnosis and treatment of malignant pleural mesothelioma. J Thorac Dis. 2013;5:E254–307.Google Scholar
  2. 2.
    Gilham C, Rake C, Burdett G, et al. Pleural mesothelioma and lung cancer risks in relation to occupational history and asbestos lung burden. Occup Environ Med. 2016;73:290–9.Google Scholar
  3. 3.
    Rake C, Gilham C, Hatch J, Darnton A, Hodgson J, Peto J. Occupational, domestic and environmental mesothelioma risks in the British population: a case-control study. Br J Cancer. 2009;100:1175–83.Google Scholar
  4. 4.
    Okello C, Treasure T, Nicholson AG, Peto J, Moller H. Certified causes of death in patients with mesothelioma in South East England. BMC Cancer. 2009;9:28.Google Scholar
  5. 5.
    Bruni BM, Pacella A, MazziottiTagliani S, Gianfagna A, Paoletti L. Nature and extent of the exposure to fibrous amphiboles in Biancavilla. Sci Total Environ. 2006;370:9–16.Google Scholar
  6. 6.
    Proietti L, Migliore M, Polosa R, Comba P, Circo C, Di Maria GU. Malignant pleural mesothelioma in housewives in the province of Catania. Recenti Prog Med. 2004;95:365–8.Google Scholar
  7. 7.
    Yamashita Y, Harada H, Mukaida H, Kaneko M. Extrapleural pneumonectomy plus rib resection for malignant pleural mesothelioma: a case report. J Cardiothorac Surg. 2014;9:176.Google Scholar
  8. 8.
    Patel SC, Dowell JE. Modern management of malignant pleural mesothelioma. Lung Cancer (Auckl). 2016;7:63–72.Google Scholar
  9. 9.
    Taioli E, Wolf AS, Camacho-Rivera M, et al. Determinants of Survival in Malignant Pleural Mesothelioma: A Surveillance, Epidemiology, and End Results (SEER) Study of 14,228 Patients. PLoS One. 2015;10:e0145039.Google Scholar
  10. 10.
    Rice D, Rusch V, Pass H, et al. Recommendations for uniform definitions of surgical techniques for malignant pleural mesothelioma: a consensus report of the international association for the study of lung cancer international staging committee and the international mesothelioma interest group. J Thorac Oncol. 2011;6:1304–12.Google Scholar
  11. 11.
    Hasani A, Alvarez JM, Wyatt JM, et al. Outcome for patients with malignant pleural mesothelioma referred for Trimodality therapy in Western Australia. J Thorac Oncol. 2009;4:1010–6.Google Scholar
  12. 12.
    Sugarbaker DJ. Macroscopic complete resection: the goal of primary surgery in multimodality therapy for pleural mesothelioma. J Thorac Oncol. 2006;1:175–6.Google Scholar
  13. 13.
    Sugarbaker DJ, Garcia JP, Richards WG, et al. Extrapleural pneumonectomy in the multimodality therapy of malignant pleural mesothelioma. Results in 120 consecutive patients. Ann Surg. 1996;224:288–94.Google Scholar
  14. 14.
    Sugarbaker DJ, Flores RM, Jaklitsch MT, et al. Resection margins, extrapleural nodal status, and cell type determine postoperative long-term survival in trimodality therapy of malignant pleural mesothelioma: results in 183 patients. J Thorac Cardiovasc Surg. 1999;117:54–63.Google Scholar
  15. 15.
    Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg. 2004;128:138–46.Google Scholar
  16. 16.
    Stewart DJ, Martin-Ucar A, Pilling JE, Edwards JG, O'Byrne KJ, Waller DA. The effect of extent of local resection on patterns of disease progression in malignant pleural mesothelioma. Ann Thorac Surg. 2004;78:245–52.Google Scholar
  17. 17.
    Waller DA. Malignant mesothelioma-British surgical strategies. Lung Cancer. 2004;45:S81–4.Google Scholar
  18. 18.
    Stewart DJ, Martin-Ucar AE, Edwards JG, West K, Waller DA. Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations. Eur J Cardiothorac Surg. 2005;27:373–8.Google Scholar
  19. 19.
    Treasure T, Sedrakyan A. Pleural mesothelioma: little evidence, still time to do trials. Lancet. 2004;364:1183–5.Google Scholar
  20. 20.
    Treasure T, Waller D, Tan C, et al. The Mesothelioma and Radical surgery randomized controlled trial: the Mars feasibility study. J Thorac Oncol. 2009;4:1254–8.Google Scholar
  21. 21.
    Cao CQ, Yan TD, Bannon PG, McCaughan BC. A systematic review of extrapleural pneumonectomy for malignant pleural mesothelioma. J Thorac Oncol. 2010;5:1692–703.Google Scholar
  22. 22.
    Flores RM, Zakowski M, Venkatraman E, et al. Prognostic factors in the treatment of malignant pleural mesothelioma at a large tertiary referral center. J Thorac Oncol. 2007;2:957–65.Google Scholar
  23. 23.
    Utley M, Fiorentino F, Treasure T. Obtaining an upper estimate of the survival benefit associated with surgery for mesothelioma. Eur J Cardiothorac Surg. 2010;38:241–4.Google Scholar
  24. 24.
    Treasure T, Lang-Lazdunski L, Waller D, et al. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol. 2011;12:763–72.Google Scholar
  25. 25.
    Weder W, Stahel RA, Baas P, et al. The MARS feasibility trial: conclusions not supported by data. Lancet Oncol. 2011;12:1093–4.Google Scholar
  26. 26.
    Rusch V, Baldini EH, Bueno R, et al. The role of surgical cytoreduction in the treatment of malignant pleural mesothelioma: Meeting summary of the International Mesothelioma Interest Group Congress, September 11-14, 2012, Boston, Mass. J Thorac Cardiovasc Surg. 2013;145:909–10.Google Scholar
  27. 27.
    Bliss JM, Coombes G, Darlison L, et al. The MARS feasibility trial: correspondence. Lancet Oncol. 2011;12:1094–5.Google Scholar
  28. 28.
    Treasure T, Utley M, O'Byrne K. MARS: a sense of perspective and an inconvenient truth. J Thorac Oncol. 2013;8:e48–9.Google Scholar
  29. 29.
    Hiddinga BI, van Meerbeeck JP. Surgery in mesothelioma - where do we go after MARS? J Thorac Oncol. 2013;8:525–9.Google Scholar
  30. 30.
    Lee YC. Surgical resection of mesothelioma: an evidence-free practice. Lancet. 2014;384:1080–1.Google Scholar
  31. 31.
    Bovolato P, Casadio C, Bille A, et al. Does surgery improve survival of patients with malignant pleural mesothelioma?: a multicenter retrospective analysis of 1365 consecutive patients. J Thorac Oncol. 2014;9:390–6.Google Scholar
  32. 32.
    Rena O, Casadio C. Lack of evidence in malignant pleural mesothelioma surgery. Interact Cardiovasc Thorac Surg. 2011;12:347–8.Google Scholar
  33. 33.
    Rena O, Casadio C. Extrapleural pneumonectomy for early stage malignant pleural mesothelioma: A harmful procedure. Lung Cancer. 2012;77:151–5.Google Scholar
  34. 34.
    Rusch VW, Giroux D, Kennedy C, et al. Initial analysis of the international association for the study of lung cancer mesothelioma database. J Thorac Oncol. 2012;7:1631–9.Google Scholar
  35. 35.
    Batirel HF, Metintas M, Caglar HB, et al. Adoption of pleurectomy and decortication for malignant mesothelioma leads to similar survival as extrapleural pneumonectomy. J Thorac Cardiovasc Surg. 2016;151:478–84.Google Scholar
  36. 36.
    Azzouqa AG, Stevenson JP. The evolution of the diminishing role of extrapleural pneumonectomy in the surgical management of malignant pleural mesothelioma. Onco Targets Ther. 2016;9:7247–52.Google Scholar
  37. 37.
    Treasure T, Macbeth F. An exception that proves the rule: recurrence free survival five years after extrapleural pneumonectomy for malignant pleural mesothelioma. J Cardiothorac Surg. 2014;9:181.Google Scholar
  38. 38.
    Flores RM, Pass HI, Seshan VE, et al. Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg. 2008;135:620–6.Google Scholar
  39. 39.
    Lang-Lazdunski L, Bille A, Lal R, et al. Pleurectomy/decortication is superior to extrapleural pneumonectomy in the multimodality management of patients with malignant pleural mesothelioma. J Thorac Oncol. 2012;7:737–43.Google Scholar
  40. 40.
    Cao C, Tian D, Park J, Allan J, Pataky KA, Yan TD. A systematic review and meta-analysis of surgical treatments for malignant pleural mesothelioma. Lung Cancer. 2014;83:240–5.Google Scholar
  41. 41.
    Burt BM, Cameron RB, Mollberg NM, et al. Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: an analysis of surgical morbidity and mortality. J Thorac Cardiovasc Surg. 2014;148:30–5.Google Scholar
  42. 42.
    Taioli E, Wolf AS, Flores RM. Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma. Ann Thorac Surg. 2015;99:472–80.Google Scholar
  43. 43.
    Teh E, Fiorentino F, Tan C, Treasure T. A systematic review of lung-sparing extirpative surgery for pleural mesothelioma. J R Soc Med. 2011;104:69–80.Google Scholar
  44. 44.
    Flores RM. Pleurectomy decortication for mesothelioma: The procedure of choice when possible. J Thorac Cardiovasc Surg. 2016;151:310–2.Google Scholar
  45. 45.
    Flores RM. The mesothelioma surgery shift. J Thorac Cardiovasc Surg. 2016;151:485–6.Google Scholar
  46. 46.
    Flores RM. The mesothelioma enigma. J Thorac Cardiovasc Surg. 2015;149:1548–9.Google Scholar
  47. 47.
    Cao C, Tian DH, Pataky KA, Yan TD. Systematic review of pleurectomy in the treatment of malignant pleural mesothelioma. Lung Cancer. 2013;81:319–27.Google Scholar
  48. 48.
    Rintoul RC, Ritchie AJ, Edwards JG, et al. Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial. Lancet. 2014;384:1118–27.Google Scholar
  49. 49.
    Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg. 2006;29:829–38.Google Scholar

Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2017

Authors and Affiliations

  1. 1.Kasturba Medical College, ManipalManipal UniversityManipalIndia
  2. 2.Wythenshawe HospitalUniversity Hospital of South ManchesterManchesterUK
  3. 3.Clinical Operational Research UnitUniversity College LondonLondonUK

Personalised recommendations