A new study out of the Icahn School of Medicine at Mount Sinai and the Mount Sinai Tisch Cancer Center finds lung-sparing pleurectomy/decortication (P/D) surgery has a very low rate of early mortality. These findings are in direct contrast to those from the MARS2 trial, which reported P/D surgery carried an increased risk and poor outcomes. The outcomes in the study found zero percent in-hospital mortality and zero percent 30-day mortality, with a 4.2 percent 90-day mortality. The study involved 71 people with pleural mesothelioma who received P/D surgery at Mount Sinai between 2015 and 2021. Nearly 80 percent had epithelioid mesothelioma, a subtype of this cancer with a specific type of cell that responds better to surgery. The pre-surgery process involved all patients having PET/CT images and underwent workup for pleurectomy. P/D surgery is often referred to as “lung-sparing” because it aims to surgically remove the pleural tumor without removing the lung. Results typically show that pleurectomy and decortication is a safe procedure for the correct patient.
The Mount Sinai study, published in The Annals of Thoracic Surgery, was designed with the MARS2 trial in mind, covering the same period, 2015 to 2021. The MARS2 trial, conducted in the United Kingdom, compared outcomes of patients who received chemotherapy alone to those who received chemotherapy and pleurectomy/decortication surgery. The results sparked a major debate about whether combining chemotherapy and P/D surgery created worse survival outcomes. The Mount Sinai researchers identified patient selection, cancer subtype, extent of surgery, and use of imaging as key areas to look at in their own study. MARS2 did not mandate PET/CT imaging for trial entry, and it included patients with sarcomatoid and biphasic mesothelioma, unlike the Mount Sinai study, which excluded patients with sarcomatoid mesothelioma. MARS2 also performed extended P/D in 89 percent of surgical patients, the more invasive version of the procedure that also involves removal of the diaphragm or pericardium, unlike standard P/D which removes tumors while leaving the lung intact. MARS2 authors concluded that radical mesothelioma surgery should not be offered outside of a clinical trial. Mount Sinai, on the other hand, found that strictly limiting who receives surgery and how extensively it’s performed can improve outcomes.
Pleurectomy/decortication is not appropriate for all patients, and whoever becomes eligible is closely tied to how the surgery is performed. The difference in outcomes between MARS2 and this study may have resulted from differences “in how and in whom” the surgery was performed. The surgery is safe when patients are carefully selected, and surgery is tailored to balance tumor removal with what a patient can tolerate. In this study, removal of the diaphragm and pericardium was rare. The authors note that removing the diaphragm increases the risk of developing abdominal mesothelioma, one of the reasons lung-sparing procedures are preferred. This is a shift from more aggressive approaches in the past that included procedures like extrapleural pneumonectomy. Extrapleural pneumonectomy removes the entire lung and surrounding tissues. The study reinforces the fact that surgery should remain in the conversation for mesothelioma treatment and can lead to long term survivorship. The Mount Sinai results suggest that with the right patient and the right approach, P/D surgery can be both safe and effective.
Sources:
“Mount Sinai study strengthens landmark evidence supporting lung-sparing surgery, offering hope for mesothelioma patients” EurekAlert! (February 12, 2026). [Link]
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