Webinar Recap: Surgery for Pleural Mesothelioma

Our most recent exclusive webinar, Surgery for Pleural Mesothelioma, gave patients and their families a chance to hear directly from one of the world’s leading mesothelioma surgeons. Thoracic surgeon Dr. Raja Flores, chairman of the Department of Thoracic Surgery at Mount Sinai Hospital, joined board-certified Patient Advocate Karen Selby for an in-depth conversation about surgical treatment. Dr. Flores has more than 30 years of experience treating people diagnosed with pleural mesothelioma.

Together, they walked through who may be a candidate for mesothelioma surgery, how it fits into a broader treatment plan and what the latest research says about surgical outcomes. Their discussion gave patients and caregivers a clearer picture of what surgery can and can’t do.

The conversation covered everything from how doctors decide if surgery can help to what patients should expect during recovery. Dr. Flores also addressed one of the most confusing topics in mesothelioma treatment today, the MARS 2 trial and what it means for patients.

Why Surgery Isn’t Right for Every Patient

Surgery for pleural mesothelioma isn’t the best treatment option for every person. Dr. Flores explained that patient selection matters more than almost anything else. He shared,”Half the patients that come to see me are not candidates for surgery.” 

Dr. Flores also explained that surgery works best for people who are in early mesothelioma stages. In stages 1 and 2 the cancer stays localized within the chest. Once mesothelioma advances and spreads in stages 3 or 4, surgery isn’t the standard of care. 

“You can’t just lump all mesotheliomas together and say surgery works or surgery doesn’t work,” Dr. Flores explained. “You have to specifically pick those patients.”

A patient’s overall health matters just as much as the stage. Dr. Flores shared that he has a system to ensure surgery is the right option for each patient.

The Flores 5: Is Surgery the Right Choice for You?

Dr. Flores shared that he uses what he calls the “Flores 5” to evaluate if someone is a good candidate for mesothelioma surgery. The 5 factors considered in his system help paint a full picture of both the cancer and overall health.

Assessing Eligibility for Surgery

1. Biopsy: Confirms the diagnosis is pleural mesothelioma and identifies the specific cell type.
2. CAT scan: Gives a detailed look inside the chest and confirms the disease hasn’t spread beyond it.
3. Cardiac stress test: Confirms the heart is strong enough to handle the demands of surgery.
4. PET scan: Checks for spread outside the chest and provides a Standardized Uptake Value reading, a measure of tumor aggressiveness that helps predict surgical outcomes.
5. Pulmonary function tests: Confirm the lungs are strong enough to tolerate surgery.

A person’s specific mesothelioma cell type is also very important. There are 3 types of mesothelioma cells: epithelioid, sarcomatoid and biphasic, which has a mix of both cell types. Epithelioid tends to have the most favorable outcomes, while sarcomatoid historically has had the least favorable. 

Dr. Flores clarified, “You don’t hang your hat on any one single variable. Just because you have a certain thing that isn’t favorable doesn’t mean it’s a death sentence.”

Pleural Mesothelioma Surgery: What Are the Most Common Options?

Dr. Flores broke down the primary surgical options for people diagnosed with pleural mesothelioma. Karen Selby clearly framed both options, noting that while there is no cure for mesothelioma yet surgery can mean “a better outcome overall for the patient.”

Pleural Mesothelioma Surgery Options

• Pleurectomy decortication: P/D removes tumors while preserving the lung. Dr. Flores considers this the preferred approach for most patients today. Most people spend 5 to 6 days in the hospital, compared to 14 to 21 days after an extrapleural pneumonectomy.
• Extrapleural pneumonectomy: EPP removes the lung, the pleura, the diaphragm and the pericardium along with tumors. Dr. Flores still performs this surgery on select patients, but far less often than he once did after his own 2008 research showed P/D patients had better outcomes.

Both surgeries aim to remove as much of the tumor as possible while protecting surrounding tissue. Which surgery Dr. Flores recommends depends on each patient’s stage, cell type and overall health.

Why the Surgical Team Matters as Much as the Surgeon

Choosing a surgeon isn’t just about credentials, according to Dr. Flores. He said it’s about the entire team around that surgeon. At Mount Sinai, he works alongside medical oncologist Dr. Kenneth Rosenzweig and mesothelioma specialist Dr. Andrea Wolf. 

Every patient goes through a tumor board at Mount Sinai where the team debates the best approach together. “Surgery needs to be personalized to that person sitting in front of you,” Dr. Flores shared.

Karen also stressed that post-operative nursing care is just as critical and is often overlooked. A specialized nursing team that knows what to watch for after mesothelioma surgery makes a meaningful difference in how you’ll recover. 

“If your ICU team only sees one mesothelioma patient a year, it’s very challenging for that patient to get the post-op care that they deserve,” Karen warned. Dr. Flores agreed, adding, “It’s the nurses that get them out of the hospital.”

When choosing a mesothelioma surgeon, Dr. Flores recommends asking one simple question first: “How many mesothelioma patients do you see each year?” He advises, “If they’re only doing one a year, that’s not the best doctor for you. It’s about understanding how this disease behaves.”

What to Expect After Surgery

Recovery from pleural mesothelioma surgery is challenging. While he says “It’s a painful surgery,” he also notes most patients are up and walking the day after surgery. That movement is critical to reduce the risk of pneumonia or blood clots.

Pain management plays an important role in recovery. Dr. Flores stresses that effective pain management allows patients to breathe more deeply, move more freely and avoid the complications that set recovery back.

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Surgery for Pleural Mesothelioma: Who It Helps & Why

Hear from one of the nation’s top thoracic surgeons about how surgery can be effective for certain people with pleural mesothelioma.

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Why Dr. Flores Tells Patients to Get a Second Opinion

Both Dr. Flores and Karen encouraged patients to get a second opinion before making any treatment decision. In fact, Dr. Flores suggested seeing 2 or 3 specialists, and not just thoracic surgeons, but mesothelioma experts across disciplines. “Don’t just stick with one person,” he urged.

Karen shared that as a Patient Advocate, she often hears from patients who worry about hurting their doctor’s feelings. Karen assured, “I promise you, they won’t feel bad about it.”

Dr. Flores reminded, “It’s your body. You’ve got to decide what you’re willing to put this body through because you have to live with that body.”

The MARS 2 Trial: What It Means for Patients

The MARS 2 trial was a large study that examined if surgery improves outcomes for pleural mesothelioma patients. It compared outcomes with surgery and without surgery. Its findings sparked tough conversations in mesothelioma cancer centers across the country about multimodal approaches, eligibility criteria, surgical teams’ firsthand experiences and patients’ own goals for their health.

Karen said the trial’s findings confused many patients and shifted how some surgeons approached treatment. “It changed the behavior of so many surgeons,” she noted. She added that after the findings were released, it became harder for patients to get clear answers about whether surgery was right for them.

Dr. Flores respects the effort behind the trial, but he doesn’t think its results tell the whole story. He pointed to what he described as key limitations. First, every patient in the trial received chemotherapy before surgery, an approach Dr. Flores doesn’t follow. 

“When I see a patient, I try and figure out if surgery is the right thing for them,” he explained. “If surgery is the right thing for them, then I go ahead and I take that out.” Operating first means patients go into surgery at their strongest.

Second, the trial included patients Dr. Flores says he would never have taken to the operating room. “They did operate on several stage 4 mesothelioma patients, which we wouldn’t do,” he said. The trial also included a high share of patients with mixed and sarcomatoid tumors. 

“If you can identify those patients ahead of time, you really wouldn’t want to operate on them,” Flores emphasized. He contends surgery for patients who wouldn’t normally be eligible in his mesothelioma program likely contributed to the poorer outcomes in the trial.

Dr. David Waller, a mesothelioma surgeon who participated in the MARS 2 trial, has since published research pointing out its limitations. He spoke directly with Dr. Flores and confirmed the trial didn’t change how he treats his mesothelioma patients.

What Dr. Flores Found When He Looked at His Own Data

After the MARS 2 trial ran between 2015 and 2021, Dr. Flores and his team reviewed their own outcomes from that same period. His team recently published these findings in the Annals of Thoracic Surgery and the comparison was striking. In the MARS 2 trial, 9% of patients died within 3 months. In Dr. Flores’ data, in-hospital mortality was 0% and 30-day mortality was 0%.

“There is a way to do this operation in a safe way,” he explained. Dr. Flores said the difference comes down to patient selection. He credits careful evaluation before surgery, a highly experienced surgical team and a coordinated approach to post-operative care.