New Guidelines Say Surgery Benefits Select Mesothelioma Patients
Treatment & Doctors
Written by Sean Marchese | Edited by Amy Edel
A national panel of 15 mesothelioma specialists across surgery, medical oncology, radiation oncology and pathology reached a consensus and issued new guidelines for surgery. The experts reviewed 116 studies and data from 630 mesothelioma surgeries between 2015 and 2025. After 3 rounds of formal voting, the panel challenged reluctance to recommend mesothelioma surgery following a controversial 2025 trial.
The 2025 trial, known as the MARS2 trial, concluded that chemotherapy followed with lung-sparing surgery didn’t extend survival more than receiving chemo alone. Dr. Jeffrey Velotta, lead author of the consensus document, tells us fallout from that trial was swift.
“Referrals all of a sudden were stopping,” Dr. Velotta says. “All of a sudden everything mesothelioma just went off the face of the earth. We wouldn’t even get a chance to speak to these patients about the option of surgery. They weren’t even given that option anymore.”
The panel’s consensus, which the Society of Thoracic Surgeons has published, counters the idea that mesothelioma surgery doesn’t offer benefits. Their message is clear: Surgery offers benefits, but the key is it must be recommended for the right pleura patients, be done the right way and involve the right surgical team.
Why the Panel Came Together
Dr. Velotta doesn’t dismiss the MARS2 trial outright. He says it exposed a real gap in patient selection. Many people with pleural mesothelioma studied in the trial underwent surgery without a prior PET scan, so some had more advanced disease than doctors realized going in.
“They ended up operating on a lot of patients that were stages 3 or 4,” Dr. Velotta explains. “If they would have gotten a PET scan, they may not have needed surgery.”
To push back against a blanket no-surgery stance, the Society of Thoracic Surgeons assembled 15 of the field’s most experienced mesothelioma specialists. The panel deliberately excluded surgeons with only occasional exposure to the rare cancer.
Why Lung-Sparing Surgery Now Comes First
The panel was unambiguous on one point: Surgery that spares the lung is the preferred approach. A pleurectomy/decortication removes the cancerous lining while leaving the lung in place.
Dr. Velotta shares the example of his early-stage patient, Lawanda Ultan, who tolerated the lung-sparing surgery well at 93 years old. He suggests it’s unlikely she would have had the same successful outcome with a more aggressive surgery.
The panel consensus leans toward a less aggressive version of even the preferred surgery. Surgeons have traditionally removed the diaphragm and the lining around the heart as routine. The panel now favors preserving both when possible.
“It’s harder on the surgeon, but better recovery for the patient,” Velotta tells us, adding that the shift changed his own approach. “Before this consensus, I’d be much more aggressive about removing the diaphragm.”
The panel was very clear on its position regarding the operation that removes the entire lung, called extrapleural pneumonectomy. They said its use should be rare.
“When you remove everything, there’s just higher complication rates,” Dr. Velotta explains. “Patients don’t have as much reserve to recover, and they just do worse.”
Why a Full Medical Team and the Right Surgeon Matter
The consensus places heavy weight on multidisciplinary care. It also points patients toward doctors with specialized experience in mesothelioma treatment.
“Chemo and immunotherapy plus surgery does better, plus radiation potentially does better,” Dr. Velotta says. “You need everybody on your team on board.”
The panel’s advice on choosing a surgeon was pointed. A surgeon should specialize in mesothelioma specifically.
“It does not count if you’re a high volume thoracic surgeon, but you don’t do much mesothelioma,” Dr. Velotta clarifies. “We all agree that’s not a good evaluation of what kind of treatment that patient should get.”
Good surgical candidates, he said, tend to share a few traits: earlier-stage disease, the epithelioid cell type and strong physical function. “Are they walking around pretty good? Are they still driving?” he says, describing early signs of whether a patient might tolerate mesothelioma surgery.
What’s Still Unanswered
One major question remains open: Should chemo come before or after surgery? “There is no consensus,” Dr. Velotta says, pointing to a randomized trial that found no survival difference between the two sequences.
Newer research isn’t expected to settle that question directly. Upcoming trials are instead testing chemo combined with immunotherapy before surgery, an approach that draws on lung cancer research.
“If those show benefits, there may be a push for chemo immunotherapy first, followed by surgery,” Dr. Velotta shares.
When to Seek a Second Opinion
For patients newly diagnosed with mesothelioma, the takeaway is direct. Ask whether the surgeon evaluating you has significant mesothelioma-specific experience. Ask whether your case has gone before a full multidisciplinary team. And don’t assume a “no surgery” recommendation from a single specialist is the final word.
If a specialist doesn’t recommend surgery, patients can consider seeking a second opinion from a mesothelioma surgeon with experience treating the disease. The Mesothelioma Center’s Patient Advocates can help patients connect with specialists who can review their diagnosis and treatment options.
