Mount Sinai Study Supports Lung-Sparing Mesothelioma Surgery
Research & Clinical Trials
Written by Sean Marchese | Edited by Amy Edel
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 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.
Key Facts About the New Study
- Outcomes: 0% in-hospital mortality and 0% 30-day mortality, 4.2% 90-day mortality
- Patients: 71 people with pleural mesothelioma received P/D surgery at Mount Sinai between 2015 and 2021
- Cancer subtype: Nearly 80% had epithelioid mesothelioma, a subtype of this cancer with a specific type of cells that responds better to surgery
- Pre-surgery process: All patients had PET/CT images and underwent workup for pleurectomy
P/D surgery is often referred to as a “lung-sparing” procedure because it aims to surgically remove the pleural tumor without removing the lung. As the chair of Thoracic Surgery at Mount Sinai Health System and the study’s lead author Dr. Raja Flores tells us, “The results suggest that pleurectomy and decortication is a safe procedure for the correct kind of patient.”
Mount Sinai Study vs. MARS2 Trial
The Mount Sinai study, published in The Annals of Thoracic Surgery, was designed with the MARS2 trial directly in mind, covering the same time period, 2015 to 2021. The MARS2 trial, conducted in the U.K., compared outcomes of patients who received chemotherapy alone to those who received chemotherapy and P/D surgery.
Its 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 address in their own study.
MARS2 didn’t 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% 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 shouldn’t be offered outside of a clinical trial. Mount Sinai, however, found that strictly limiting who receives surgery and how extensively it’s performed can improve outcomes.
| Mount Sinai Study | MARS2 Trial | |
| Patients (surgery group) | 71 | 169 |
| In-hospital mortality | 0% | 4% |
| 30-day mortality | 0% | 4% |
| 90-day mortality | 4.2% | 9% |
| Median survival | Not reported | 19.3 months |
| PET/CT required | Yes, 100% | No, not mandated |
| Sarcomatoid patients included | No | Yes (5%) |
| Extended P/D rate | Not primary approach | 89% |
Who Might Be A Candidate For Surgery?
Pleurectomy/decortication isn’t appropriate for all patients, and who is eligible is closely tied to how the surgery is performed. As Dr. Flores says, the difference in outcomes between MARS2 and this study may have resulted from differences “in how and in whom” the surgery was performed. He explains, “The bottom line is that this 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. EPP removes the entire lung and surrounding tissues.
Dr. Flores adds, “This study reinforces that surgery should remain part of 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.
Questions To Ask Your Physician If You Are Considering Surgery
If you or a loved one has received a mesothelioma diagnosis and been told that surgery isn’t an option, particularly following the MARS2 trial, the Mount Sinai findings suggest it may be worth a closer look at the specifics of your case. These questions can help start that conversation and help you decide whether a second opinion makes sense.
- What is my mesothelioma subtype?
- What imaging and tests have been performed?
- Would the procedure be lung-sparing?
- What other treatments would be part of my care?
Patient selection and surgical approach play a significant role in outcomes, and not all mesothelioma programs evaluate these factors the same way. Consulting a specialist experienced in mesothelioma surgery can help determine whether P/D is appropriate for your individual diagnosis and health.
