In a groundbreaking study that challenges prevailing assumptions in thoracic oncology, researchers at the Icahn School of Medicine at Mount Sinai and the Mount Sinai Tisch Cancer Center have revealed significant advancements in the surgical management of pleural mesothelioma. This rare and aggressive malignancy, predominantly attributed to asbestos exposure, has historically posed substantial challenges in balancing effective tumor resection with patient safety. The latest findings demonstrate that pleurectomy/decortication, a lung-sparing surgical approach, can be performed with remarkably low mortality rates when patients are meticulously selected and surgical protocols are optimized. Published in the prestigious Annals of Thoracic Surgery, this observational study provides compelling evidence that reshapes the surgical landscape for mesothelioma treatment.
Pleural mesothelioma’s aggressive nature and complex anatomical considerations often limit treatment options; hence, surgery’s role remains contentious. The recent study from Mount Sinai counters the skepticism generated by the Mesothelioma and Radical Surgery 2 (MARS2) trial, conducted in 2024, which questioned the value and safety of radical surgical interventions. Unlike MARS2, where higher early postoperative mortality rates were reported, the Mount Sinai cohort experienced zero in-hospital and 30-day mortality and only a 4.2 percent mortality rate at 90 days post-surgery. This stark contrast elucidates the critical role of patient selection, surgical technique refinement, and comprehensive preoperative evaluation.
At the heart of this study’s success is the surgical technique of pleurectomy/decortication. This procedure intricately removes the diseased pleural lining and tumor masses while sparing the underlying lung parenchyma, thereby preserving pulmonary function. Such an approach significantly reduces surgical morbidity compared to extrapleural pneumonectomy, an older, more radical operation that entails removing the lung along with the pleura, diaphragm, and pericardium. Mount Sinai’s data reinforce that organ preservation should be prioritized where feasible, as it offers a meaningful balance between oncologic control and patient quality of life.
The study’s senior author, Dr. Raja M. Flores, a distinguished Professor of Surgery and Chair of Thoracic Surgery at Mount Sinai, underscores that the outcomes hinge not merely on the surgical procedure itself but on the nuanced selection of appropriate candidates. Over nearly two decades, Dr. Flores has been a pioneer in thoracic oncology research, having previously demonstrated that pleurectomy/decortication confers superior survival benefits when compared to more extensive surgeries in mesothelioma patients. This trajectory reflects an evolving understanding of mesothelioma surgery from purely oncologic aggressiveness toward personalized, patient-centric care.
Integral to these improved outcomes is the use of advanced imaging modalities and rigorous preoperative screening protocols. Modern diagnostic imaging enables precise tumor staging and identification of the epithelioid subtype of mesothelioma, which comprised nearly 80 percent of patients in the Mount Sinai cohort. This histologic subtype is associated with better surgical outcomes, and its prevalence likely influenced the favorable postoperative mortality observed. Furthermore, the study excluded patients considered for extrapleural pneumonectomy, thereby focusing on a population more amenable to lung-sparing surgery and less susceptible to severe surgical complications.
This paradigm shift reflects a broader transformation within thoracic oncology, wherein surgical candidacy is now contingent on multidimensional patient evaluation encompassing functional status, tumor biology, and individual risk profiles. Mount Sinai’s meticulous approach includes rigorous pulmonary and cardiac assessments, ensuring only those patients who can tolerate the extensive surgical procedure and recovery are offered pleurectomy/decortication. This tailored methodology contrasts with earlier trials like MARS2 and may account for divergent outcomes and interpretations regarding surgery’s efficacy.
An important contextual element is mesothelioma’s overarching clinical challenge: its limited responsiveness to traditional therapeutic modalities such as chemotherapy and radiation. This therapeutic void accentuates the urgency for surgical innovation that can safely extend survival and maintain quality of life. The Mount Sinai study, therefore, represents a significant advance by not only supporting surgery’s potential role but also establishing new benchmarks for its implementation in multidisciplinary treatment regimens.
The implications of these findings extend beyond immediate surgical outcomes. The team at Mount Sinai is currently exploring the integration of immunotherapy with surgical strategies to further enhance treatment efficacy. Preliminary investigations suggest that combining lung-sparing surgery with immune checkpoint inhibitors could potentiate anti-tumor responses, offering a promising frontier in mesothelioma management. This ongoing research underscores the institution’s commitment to translating benchside discoveries into clinical realities with tangible patient benefits.
Another notable aspect of Mount Sinai’s legacy in mesothelioma research is its historical link to Dr. Irving J. Selikoff, whose pioneering studies first established asbestos exposure as the etiologic agent in mesothelioma. His work catalyzed regulatory policies that curtailed asbestos use worldwide, thereby offering primary prevention. Today, Mount Sinai continues this legacy through comprehensive patient care programs, including those addressing mesothelioma cases linked to environmental exposures such as the World Trade Center disaster.
The study’s findings, emphasizing safety and tailored surgical care, offer renewed hope to patients and clinicians navigating the difficult terrain of pleural mesothelioma treatment. Dr. Flores articulates the essential message succinctly: while surgery may not be suitable for every patient, for carefully selected individuals at experienced centers, it remains a vital and viable path to prolonged survival. This perspective advocates for surgical consideration to remain a pivotal component of mesothelioma care discussions.
In conclusion, these contemporary outcomes from Mount Sinai challenge the prevailing skepticism about the surgical management of pleural mesothelioma. They underscore that with state-of-the-art imaging, stringent patient selection, and lung-preserving techniques, pleurectomy/decortication can be safely employed with minimum early mortality and optimal therapeutic benefit. This study not only advances surgical science but also offers a beacon for evidence-based, patient-centered oncology in the face of one of the most daunting thoracic malignancies.
Subject of Research: People
Article Title: Disaster on MARS2? Lessons Learned from Modern Day Outcomes of Surgery for Pleural Mesothelioma
News Publication Date: 2-Feb-2026
Web References:
DOI: 10.1016/j.athoracsur.2026.01.025
MARS2 trial full text: The Lancet Respiratory Medicine
Image Credits: Mount Sinai Health System
Keywords: Mesothelioma, Lung cancer
