Introduction: The surgical arm of the Mesothelioma and Radical Surgery (MARS) trial involved a multimodal approach, with combined therapy consisting of chemotherapy, complete gross resection, and radiation therapy. However, the MARS trial did not compare surgery with chemotherapy, and the survival and quality of life outcomes of this trial's surgical arm were inferior to those of the non-surgical arm. Methods for achieving complete gross resection (macroscopic complete response [MCR]) include extrapleural pneumonectomy (EPP), wherein the pleura, lung, diaphragm, and pericardium are removed en bloc, and pleurectomy/decortication (P/D), wherein the affected lung is preserved. Nonetheless, the most effective therapy remains unclear.Areas covered: Here, surgery post-neoadjuvant chemotherapy for malignant pleural mesothelioma with either EPP or P/D has been discussed, along with trimodal and bimodal therapies.Expert opinion: With the development of post-P/D radiation therapy, it is currently possible to truly compare EPP with P/D. Moreover, R0 resection cannot be achieved with either EPP or P/D; thus, both must incorporate debulking, although the two procedures are largely incompatible. Therefore, there is a need to rebuild the status of surgery as a multimodal therapy.
Keywords: Bimodality; cytoreduction; extrapleural pneumonectomy; macroscopic complete resection; malignant pleural mesothelioma; nivolumab; pleurectomy/decortication; trimodality.