The Role of Surgery in Malignant Pleural Mesothelioma

Malignant pleural mesothelioma (MPM) is a fatal malignancy associated with asbestos exposure. Although various therapies have been used in the past, including surgery, chemotherapy, radiotherapy, immunotherapy, and more recently targeted therapy, prognosis still remains poor. Radical surgery including extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D) is being offered to obtain maximal cytoreduction in the context of multimodality therapy in patients with MPM. Growing evidence suggests that EPP might be detrimental, while recent reports suggest that P/D is better tolerated, producing low mortality and morbidity and allowing patients to receive adjuvant therapies in the form of either chemotherapy alone, or combined chemoradiotherapy. Many now believe that P/D should be the default procedure in multimodality regimens, although this remains to be proven in a large randomized trial. Apart from its therapeutic role, surgery has also an important role to play in pleural mesothelioma in establishing or refining diagnosis and in controlling symptoms and improving quality of life in many patients whose life expectancy is limited. Recent progress in molecular analyses and biomarkers should help with patient selection for surgery, immunotherapy and systemic therapies in the near future.