Disaster on MARS2? Lessons Learned from Modern Day Outcomes of Surgery for Pleural Mesothelioma

The Mesothelioma and Radical Surgery 2 (MARS2) trial has drawn into question pleurectomy/decortication (PD) for the treatment of pleural mesothelioma. This trial's evaluation of resectability (poor positron emission tomography/computed tomography utilization, patients with non-epithelioid subtypes, etc) and preference for extended PD (89% patients underwent this) may have led to the high in-hospital and 30-day mortality (both 4%) and 90-day mortality (9%). Many argue that surgical treatment for mesothelioma offers better outcomes in appropriately identified patients. The argument is based on case series prior to 2015 with limited discussion of surgical details. We present our institutional outcomes in carefully characterized pleural mesothelioma during the time MARS2 was completed, highlighting management and outcomes in the same period.

Our database was screened for patients from 2015-2021 treated with PD for pleural mesothelioma. Patients undergoing extrapleural pneumonectomy were excluded. Electronic medical records were queried for dates of surgery, last follow-up, and death; preoperative tests; operative details; and postoperative outcomes. Electronically available obituaries were reviewed to supplement survival data. Descriptive variables and postsurgical survival were analyzed.

Seventy-one patients underwent PD for pleural mesothelioma. Histologic diagnosis demonstrated 56 (78.9%) epithelioid, 13 (18.3%) biphasic, and 2 (2.8%) sarcomatoid PM. All 71 (100%) had pulmonary function tests and positron emission tomography/computed tomography. In-hospital and 30-day mortality were 0 and 90-day mortality was 3 of 71 (4.2%).

PD can be done safely, with low postoperative mortality. With strict selection criteria and resection focused on balancing cytoreduction with patients' tolerance for aggressive surgery, short-term complications and mortality of PD in pleural mesothelioma can be limited.