Expert Panel Recap: When Surgery Still Matters for Pleural Mesothelioma in 2026

The role of surgery in pleural mesothelioma has never been more debated — or more clearly defined. In April 2026, the Society of Thoracic Surgeons published its Expert Consensus on Multimodal Treatment of Pleural Mesothelioma, bringing together an international panel of thoracic surgeons, oncologists, and pathologists to settle the question: does surgery still belong in the mesothelioma treatment plan?^[1] The answer is yes, but only under specific conditions that patients and families need to understand.

Executive Summary

The 2026 STS Expert Consensus confirms that surgery remains part of the multimodal treatment strategy for carefully selected pleural mesothelioma patients, but with important caveats. Pleurectomy/decortication (P/D) is now strongly favored over extrapleural pneumonectomy (EPP) based on lower mortality and comparable survival outcomes.^[1] The controversial MARS2 trial, which found no survival benefit from surgery, has been challenged by institutional data showing that patient selection — not the surgery itself — determines outcomes.^[3] Meanwhile, perioperative immunotherapy trials are demonstrating that combining checkpoint inhibitors with surgery may produce the best results yet: one phase 2 trial reported median overall survival of 28.6 months with neoadjuvant nivolumab plus ipilimumab followed by surgery.^[5] The emerging consensus is clear: surgery works when the right patient gets the right operation at the right center, combined with systemic therapy.

P/D Favored

STS 2026 consensus strongly favors P/D over EPP for pleural mesothelioma

2% vs. 5%

30-day mortality: P/D vs EPP in meta-analysis

28.6 Months

Median OS with neoadjuvant nivo+ipi followed by surgery (phase 2)

0% vs. 4%

30-day mortality: Mt. Sinai strict selection vs MARS2 trial

What Did the 2026 STS Expert Consensus Conclude About Mesothelioma Surgery?

The Society of Thoracic Surgeons published its Expert Consensus Document on the multimodal treatment of pleural mesothelioma in the Annals of Thoracic Surgery in April 2026. An international, multidisciplinary panel used a modified Delphi process with at least 75% agreement across three voting rounds to develop 13 consensus statements addressing key clinical questions.^[1]

The panel reached strong consensus on several foundational points. Accurate diagnosis requires adequate pleural biopsy specimens — not just cytology from pleural fluid. Clinical evaluation should include, at minimum, both CT and PET imaging. Most importantly, all therapeutic decisions should be discussed by a multidisciplinary tumor board that includes thoracic surgeons with specific expertise in mesothelioma treatment.^[1]

"The STS consensus document is exactly what this field needed. For years, the debate about surgery in mesothelioma has generated more heat than light. What this panel has done is lay out the conditions under which surgery adds value — and be honest about when it does not. That clarity serves patients far better than the all-or-nothing arguments we have heard before."
— David Foster, 18+ Years Mesothelioma Advocacy, Danziger & De Llano

The consensus document's central surgical recommendation is unambiguous: if surgical resection is deemed appropriate, it should be part of a multimodal treatment plan, and pleurectomy/decortication (P/D) or extended P/D is strongly favored over extrapleural pneumonectomy (EPP).^[1] This reflects a decade-long shift away from EPP — a more radical procedure that removes the entire lung — toward the lung-sparing P/D approach.

Why Has P/D Replaced EPP as the Preferred Surgical Approach?

The shift from EPP to P/D has been driven by accumulating evidence that removing the entire lung does not improve survival but does increase complications and mortality. A 2018 meta-analysis published in the Journal of Surgical Oncology found that EPP carried a 30-day mortality rate of 5% compared to 2% for P/D. The complication rate was also significantly higher: 46% for EPP versus 24% for P/D. Supraventricular arrhythmia was more than five times more frequent after EPP (20% vs 5%).^[7]

Despite the higher risk profile, EPP does not deliver superior survival. The 2026 STS Expert Consensus panel reviewed the contemporary literature and concluded that P/D achieves comparable oncologic outcomes with substantially lower perioperative morbidity and mortality.^[1] A recent review in Current Opinion in Pulmonary Medicine characterized the overall trend as a "move away from aggressive surgical cytoreduction towards more biologically-informed, less invasive management."^[2]

This does not mean EPP has been completely abandoned. In rare cases where disease involves the lung parenchyma to a degree that makes P/D technically impossible, EPP may still be considered. But those cases are the exception, not the standard approach. The practical implication for patients is clear: if a surgeon recommends EPP, patients should seek a second opinion at a mesothelioma treatment center where P/D expertise is available.^[12]

What Did the MARS2 Trial Really Show — and Why Do Experts Disagree?

The Mesothelioma and Radical Surgery 2 (MARS2) trial is the most controversial study in mesothelioma surgery. This randomized controlled trial compared pleurectomy/decortication to no surgery and concluded that P/D did not improve overall survival — a finding that prompted some oncologists to question whether any mesothelioma surgery is justified.^[4]

However, several leading thoracic surgeons have raised serious methodological concerns. A team from Mount Sinai's Department of Thoracic Surgery published a detailed analysis in the Annals of Thoracic Surgery, noting that MARS2 had notable issues with patient selection: poor PET/CT utilization, inclusion of patients with non-epithelioid subtypes (who respond poorly to surgery), and a strong preference for extended P/D (89% of patients), which is a more aggressive procedure than standard P/D.^[3]

The MARS2 trial reported a 30-day mortality of 4% and a 90-day mortality of 9% — rates that the Mount Sinai team argued reflected suboptimal patient selection rather than an inherent failure of surgery. To demonstrate this point, they presented their own institutional outcomes from the same time period (2015-2021): 71 patients underwent P/D with strict selection criteria, and the result was 0% in-hospital and 30-day mortality. The 90-day mortality was 4.2% — less than half the MARS2 rate.^[3]

"The MARS2 trial asked the right question but got a misleading answer because of how they selected patients. When you include sarcomatoid patients and do not use PET scans consistently, you are operating on people who probably should not have been in the operating room. It is not that surgery failed — it is that the trial did not test surgery under conditions where it is known to work."
— David Foster, 18+ Years Mesothelioma Advocacy, Danziger & De Llano

The STS Expert Consensus panel did not dismiss MARS2 but placed it in context: surgery can be done safely and effectively with low mortality when surgeons with mesothelioma expertise apply strict selection criteria and perform the appropriate procedure for each patient.^[1]

Who Should — and Should Not — Be Considered for Mesothelioma Surgery?

Patient selection is the single most important factor in surgical outcomes for pleural mesothelioma. The 2026 STS consensus and supporting evidence point to specific criteria that define appropriate surgical candidates.^[1]

Histology matters most: Epithelioid mesothelioma responds best to surgery. The Mount Sinai series was 78.9% epithelioid. Non-epithelioid subtypes (sarcomatoid and biphasic) have substantially worse surgical outcomes and are generally not recommended for radical resection.^[3]
Imaging is essential: Both CT and PET/CT should be performed before any surgical decision. The STS consensus mandates these as minimum workup requirements. The Mount Sinai team noted that 100% of their patients had both PET/CT and pulmonary function tests — a standard the MARS2 trial did not consistently meet.^[1]^[3]
Multidisciplinary tumor board review: The decision to operate should never rest with a single physician. The STS consensus states that therapeutic decisions should be discussed by a multidisciplinary tumor board that includes thoracic surgeons with mesothelioma expertise.^[1]
Functional fitness: Adequate cardiopulmonary reserve is required. Patients need pulmonary function testing to determine whether they can tolerate the physiological demands of surgery and recovery.
No distant metastases: Surgery is a local therapy. Patients with disease that has spread beyond the chest are not surgical candidates.
Center expertise: Outcomes are significantly better at high-volume centers with dedicated mesothelioma programs. The difference between 0% and 4% 30-day mortality underscores the importance of surgeon and center experience.^[3]

How Is Immunotherapy Changing the Role of Surgery in Mesothelioma?

The most exciting development in mesothelioma surgery is not a new surgical technique — it is the integration of immunotherapy into the perioperative treatment plan. While immunotherapy has become the standard first-line treatment for unresectable pleural mesothelioma, its role around the time of surgery is an active area of investigation.^[8]

The most significant data comes from a phase 2 trial (NCT03918252) led by investigators at Johns Hopkins and MD Anderson, published in Nature Medicine. This study tested neoadjuvant nivolumab alone (Arm A, 16 patients) or nivolumab plus ipilimumab (Arm B, 14 patients) before surgery, followed by optional chemotherapy and/or radiotherapy and one year of nivolumab maintenance.^[5]

The results were notable. In the dual immunotherapy arm (Arm B), 85.7% of patients successfully proceeded to surgery. Median progression-free survival was 19.8 months and median overall survival was 28.6 months — among the longest survival figures reported for any multimodal mesothelioma treatment approach. The trial also demonstrated the utility of circulating tumor DNA (ctDNA) as a biomarker: patients with persistent ctDNA during neoadjuvant therapy who did not achieve complete surgical resection had significantly shorter progression-free survival.^[5]

A comprehensive review published in Critical Reviews in Oncology/Hematology examined the broader landscape of perioperative immunotherapy for pleural mesothelioma. Across early-phase trials, major pathological response was achieved in up to 25% of patients, with median progression-free survival ranging from 14 to 19 months. The review noted that while these results are encouraging, they trail behind the perioperative immunotherapy outcomes seen in non-small cell lung cancer, where major pathological response rates exceed 50%.^[6]

"The idea of giving immunotherapy before surgery — shrinking the tumor first, then removing what is left — is transforming how we think about mesothelioma treatment sequencing. The Johns Hopkins trial showed nearly 29 months median survival with this approach. That is genuinely competitive with the best outcomes from any treatment strategy in this disease."
— David Foster, 18+ Years Mesothelioma Advocacy, Danziger & De Llano

What Clinical Trials Are Currently Testing Surgery With Immunotherapy?

Several active clinical trials are recruiting patients to further define the optimal combination of surgery and immunotherapy for pleural mesothelioma:

NCT05647265 (Alliance): A phase 2 trial testing neoadjuvant nivolumab plus ipilimumab specifically in sarcomatoid and biphasic mesothelioma — the subtypes that historically do worst with surgery alone. This trial is open at 131 sites across the United States.
NCT03760575 (Penn Medicine): A phase 1 trial combining pembrolizumab with chemotherapy and indocyanine green (ICG) image-guided surgery, aiming to improve the completeness of surgical resection using fluorescence-guided visualization.
NCT07121374 (NECIM, University of Antwerp): A feasibility study testing whether neoadjuvant chemo-immunotherapy can convert initially inoperable epithelioid pleural mesothelioma to a resectable state, followed by extended pleurectomy/decortication.
NCT07126509 (University of Chicago): A pilot study evaluating partial pleurectomy — a less extensive procedure — for borderline and unresectable pleural mesothelioma, exploring whether a cytoreductive rather than curative surgical approach offers palliative benefits.

Patients interested in surgical trials should discuss eligibility with a specialized mesothelioma treatment team. Clinical trial participation provides access to the newest treatment combinations and contributes to the evidence base that drives future treatment guidelines.^[11]

What Does Multimodal Treatment Look Like for Surgical Candidates?

The 2026 STS consensus is explicit: if surgery is deemed appropriate, it should be part of a multimodal treatment plan — not performed in isolation.^[1] The practical question is how to combine surgery with systemic therapy, and the answer is evolving rapidly.

The traditional approach combined surgery with adjuvant (post-operative) chemotherapy, typically pemetrexed and cisplatin or carboplatin. Some centers also use radiation therapy to the surgical field, particularly after EPP where the lung has been removed and the chest wall can tolerate higher radiation doses.^[11]

The emerging paradigm shifts the systemic therapy to the neoadjuvant (pre-operative) setting, using immunotherapy before surgery. The rationale is that treating the intact tumor with immune checkpoint inhibitors may generate a stronger immune response than treating after surgery, when much of the tumor antigen has been removed. The Johns Hopkins phase 2 trial supports this approach, showing both feasibility and promising survival outcomes.^[5]

Regardless of the specific treatment sequence, the key message from the STS consensus and the broader literature is that surgery alone is insufficient. Mesothelioma is a systemic disease that requires systemic treatment. Surgery can provide local control — removing visible tumor burden — but it must be paired with therapies that address microscopic disease throughout the body.^[1]^[2]

How Should Patients and Families Use This Information?

For patients and families navigating a mesothelioma diagnosis, the surgical landscape can feel overwhelming. The practical takeaways from the current expert consensus are straightforward:

Get evaluated at a high-volume mesothelioma center. The data is clear that surgical outcomes depend heavily on institutional expertise. A specialized treatment center with a multidisciplinary tumor board can determine whether surgery is appropriate for your specific case and, if so, which approach is best.^[12]

Ask about immunotherapy. Whether you are a surgical candidate or not, immunotherapy is now the standard first-line treatment for unresectable pleural mesothelioma. For surgical candidates, clinical trials combining immunotherapy with surgery represent the frontier of treatment and may offer the best long-term outcomes.^[8]^[9]

Understand your rights. Mesothelioma caused by asbestos exposure creates both medical needs and legal rights. Compensation through experienced mesothelioma attorneys can help cover the cost of surgery at specialized centers, travel expenses, and ongoing treatment. With over $30 billion available in asbestos trust funds, pursuing financial recovery early ensures families have the resources to access the best available treatment.

Do not delay. Both treatment and legal timelines have deadlines. Immunotherapy is most effective when started early, surgical windows can close as disease progresses, and statutes of limitations restrict the time available to file compensation claims. Take our free case evaluation quiz to connect with experienced advocates who can help you navigate both treatment options and legal rights, or contact Danziger & De Llano at (855) 699-5441 for a confidential consultation.

Every consultation is free, and all legal representation is on a contingency basis — you pay nothing unless we recover compensation for you.

Frequently Asked Questions

Is surgery still recommended for pleural mesothelioma in 2026?

Yes, but only as part of a multimodal treatment plan and only for carefully selected patients. The 2026 Society of Thoracic Surgeons Expert Consensus confirms that surgical resection remains appropriate when performed by experienced thoracic surgeons at high-volume centers, combined with systemic therapy. However, surgery alone is not recommended, and the decision to operate should be made by a multidisciplinary tumor board.

What is the difference between P/D and EPP surgery for mesothelioma?

Pleurectomy/decortication (P/D) removes the diseased pleural lining while preserving the lung. Extrapleural pneumonectomy (EPP) removes the entire lung along with the pleura, diaphragm, and pericardium. The 2026 STS Expert Consensus strongly favors P/D or extended P/D over EPP based on lower 30-day mortality (approximately 2% for P/D vs 5% for EPP in meta-analyses) and comparable survival outcomes.

What did the MARS2 trial show about mesothelioma surgery?

The MARS2 randomized controlled trial compared pleurectomy/decortication to no surgery and found no overall survival benefit from surgery. However, experts have challenged these results, noting that MARS2 had high 30-day and 90-day mortality rates (4% and 9% respectively) and included patients with non-epithelioid histology who are poor surgical candidates. A Mount Sinai study of 71 patients using strict selection criteria achieved 0% 30-day mortality, suggesting that patient selection — not the surgery itself — was the problem in MARS2.

Who is a good candidate for mesothelioma surgery?

The best surgical candidates have epithelioid histology, early-stage disease visible on PET/CT imaging, good overall fitness (ECOG performance status 0-1), adequate cardiopulmonary reserve, and no evidence of distant metastases. Non-epithelioid mesothelioma patients are generally not recommended for radical surgery. The 2026 STS Expert Consensus emphasizes that all cases should be evaluated by a multidisciplinary tumor board that includes thoracic surgeons experienced in mesothelioma.

Can immunotherapy be combined with mesothelioma surgery?

Emerging evidence supports combining immunotherapy with surgery. A phase 2 trial at Johns Hopkins (NCT03918252) tested neoadjuvant nivolumab or nivolumab plus ipilimumab before surgery in resectable pleural mesothelioma. Patients receiving dual immunotherapy before surgery achieved a median overall survival of 28.6 months and a median progression-free survival of 19.8 months. Several additional trials are currently recruiting to further define the role of perioperative immunotherapy.

What is the survival rate after mesothelioma surgery?

Survival after pleural mesothelioma surgery depends on histology, stage, completeness of resection, and whether surgery is combined with other therapies. In multimodal settings, median overall survival after P/D ranges from approximately 18-24 months for epithelioid mesothelioma. Five-year survival is achievable in a subset of patients. For peritoneal mesothelioma treated with CRS-HIPEC, published multi-institutional data reports approximately 47% five-year survival.

References

Velotta JB, Roden AC, Rice J, et al. The Society of Thoracic Surgeons 2026 Expert Consensus on the Multimodal Treatment of Pleural Mesothelioma. Ann Thorac Surg. 2026 — pubmed.ncbi.nlm.nih.gov
Tan DCX, Chin WL, Lee YCG. Update on pleural mesothelioma. Curr Opin Pulm Med. 2026 — pubmed.ncbi.nlm.nih.gov
Gulati S, Wolf A, Mehrotra-Varma J, et al. Disaster on MARS2? Lessons Learned from Modern Day Outcomes of Surgery for Pleural Mesothelioma. Ann Thorac Surg. 2026 — pubmed.ncbi.nlm.nih.gov
Gulati S, Wolf AS, Flores RM. Should Treatment of Mesothelioma Include Surgery? MARS2 Fails to Land. Semin Thorac Cardiovasc Surg. 2024;38(1):67-70 — pubmed.ncbi.nlm.nih.gov
Reuss JE, Forde PM, Anagnostou V, et al. Perioperative nivolumab or nivolumab plus ipilimumab in resectable diffuse pleural mesothelioma: a phase 2 trial. Nat Med. 2025;31(12):4097-4108 — pubmed.ncbi.nlm.nih.gov
Ambrosini P, Stanzi A, Lo Russo G, et al. Towards a new approach in pleural mesothelioma: Perioperative immunotherapy and its implications. Crit Rev Oncol Hematol. 2025;215:104864 — pubmed.ncbi.nlm.nih.gov
van Gerwen M, Wolf A, Liu B, Flores R, Taioli E. Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma. J Surg Oncol. 2018;118(7):1178-1187 — pubmed.ncbi.nlm.nih.gov
ASCO Guideline Update: Treatment of Malignant Pleural Mesothelioma — pubmed.ncbi.nlm.nih.gov
Scherpereel A, Baas P, Nowak AK, et al. Five-Year Clinical Outcomes With Nivolumab Plus Ipilimumab Versus Chemotherapy in CheckMate 743. J Clin Oncol. 2026;44(9):742-749 — pubmed.ncbi.nlm.nih.gov
NCI SEER - Mesothelioma Cancer Statistics — seer.cancer.gov
NCCN - Malignant Pleural Mesothelioma Guidelines — nccn.org
Mesothelioma Treatment Centers - WikiMesothelioma — wikimesothelioma.com

Mesothelioma Surgery Options 2026: EPP vs P/D and Emerging Techniques — Detailed comparison of surgical procedures, recovery timelines, and candidacy criteria
ASCO Updates Mesothelioma Guidelines: Immunotherapy Doubles 5-Year Survival — How immunotherapy became the first-line standard of care for all histologies
Mesothelioma Treatment Comparison 2026 — Side-by-side comparison of surgery, chemotherapy, and immunotherapy outcomes