A national panel of 15 mesothelioma specialists across surgery, medical oncology, radiation oncology, and pathology reached a consensus and issued new guidelines for surgery. The experts reviewed 116 studies and data from 630 mesothelioma surgeries between 2015 and 2025. After three rounds of formal voting, the panel challenged reluctance to recommend mesothelioma surgery following a controversial 2025 trial. The 2025 trial, known as MARS2, concluded that chemotherapy followed with lung sparing surgery did not extend survival more than receiving chemotherapy alone. Fallout from the trial was swift. Doctors lost referrals and stopped being able to speak to patients about surgery. They were not given that option. The panel’s consensus, which the Society of Thoracic Surgeons has published, counters the idea that mesothelioma surgery doesn’t offer benefits. Their message is clear: Surgery offers benefits, but the key is it must be recommended for the right pleural mesothelioma patients, be done the right way, and involve the right surgical team.
One doctor does not dismiss the MARS2 trial outright. He says it exposed a real gap in patient selection. Many people with pleural mesothelioma studied in the trial underwent surgery without a prior PET scan, so some had more advanced disease than doctors realized going in. Many patients were operated on when they were stage 3 or 4. If they were given a PET scan, they may not have needed surgery. To push back against a blanket no-surgery stance, the Society of Thoracic Surgeons assembled 15 of the field’s most experienced mesothelioma specialists. The panel deliberately excluded surgeons with only occasional exposure to the rare cancer.
The panel was unambiguous on one point: Surgery that spares the lung is the preferred approach. A pleurectomy/decortication removes the cancerous lining while leaving the lung in place. One patient, who was 93 years old when receiving the lung sparing surgery, tolerated the treatment well. It is unlikely that she would have had the same successful outcome with a more aggressive surgery. The panel consensus leans toward a less aggressive version of even the preferred surgery. Surgeons have traditionally removed the diaphragm and the lining around the heart as routine. The panel now favors preserving both when possible. It can be hard for the surgeon, but better for the patient. Before this consensus, the doctor would be much more aggressive about removing the diaphragm when treating patients. The panel was very clear on its position regarding the operation that removes the entire lung, called extrapleural pneumonectomy. They said its use should be rare. This is due to the higher chance of complication rates when removing everything. Patients do not have as much strength to recover, and they end up doing worse.
The consensus places heavy weight on multidisciplinary care. It also points patients toward doctors with specialized experience in mesothelioma treatment. Chemotherapy and immunotherapy plus surgery does better, plus radiation potentially does better. Everybody on the treatment team needs to be on the same page. The panel’s advice on choosing a surgeon was pointed. A surgeon should specialize in mesothelioma specifically. People should not want a high-volume thoracic surgeon that doesn’t specialize in mesothelioma specifically. Good surgical candidates tend to share a few traits: earlier-stage disease, the epithelioid cell type, and strong physical function. (Are they walking around pretty well? Are they still driving?)
One question remains open: Should chemotherapy come before or after surgery? There is no consensus, based on data from a randomized trial that found no survival difference between the two sequences. Newer research is not expected to settle that question directly. Upcoming trials are instead testing chemotherapy combined with immunotherapy before surgery, an approach that draws on lung cancer research. If benefits are shown, chemoimmunotherapy will be pushed first, followed by surgery.
For patients newly diagnosed with mesothelioma, the takeaway is direct. Ask whether the surgeon evaluating you has significant mesothelioma-specific experience. Ask whether your case has gone before a full multidisciplinary team, and do not assume a “no surgery” recommendation from a single specialist is the final word. If a specialist does not recommend surgery, patients can consider seeking a second opinion from a mesothelioma surgeon with experience treating the disease.
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