The Society of Thoracic Surgeons 2026 Expert Consensus on the Multimodal Treatment of Pleural Mesothelioma

The Annals of Thoracic Surgery 2026 July [Link]

Jeffrey B Velotta, Anja C Roden, Jonathan Rice, Charles B Simone, Bansari Upadhyay, Pallavi Sood, Daniel L Miller, R Taylor Ripley, Andrea Wolf, Bryan M Burt, Samuel S Kim, Isabelle Opitz, Hedy L Kindler, Harvey I Pass, J W Awori Hayanga, Valerie Rusch, Raphael Bueno

Abstract

Background: Pleural mesothelioma (PM) is a rare and complex thoracic malignancy for which treatment regimens continue to evolve. The role of surgery in the management of PM is controversial. We reviewed contemporary literature to provide consensus recommendations from an expert multidisciplinary panel on the multimodal treatment of PM with an emphasis on surgical intervention to update management pathways.

Methods: An international, multidisciplinary panel developed Population, Intervention, Comparator, Outcomes (PICO)-based questions and conducted a comprehensive literature review to identify relevant literature. Consensus statements were developed using a modified Delphi process with at least 75% agreement over three voting rounds.

Results: The panel developed 13 PICO questions, and detailed summary statements were provided for each PICO subtopic based on systematic literature review and multidisciplinary expert panel discussion. There was strong consensus that accurate diagnosis depends on adequate pleural biopsy specimens and that clinical evaluation should include, at a minimum, computed tomographic and positron emission tomographic imaging. Therapeutic decisions should be discussed by a multidisciplinary tumor board, including thoracic surgeons with expertise in PM treatment. If surgical resection is deemed appropriate, it should be part of a multimodal treatment plan. Pleurectomy/decortication or extended pleurectomy/decortication is strongly favored over extrapleural pneumonectomy as the approach to resection.

Conclusions: This Society of Thoracic Surgeons Expert Consensus Document includes contemporary treatment recommendations for PM based on systematic literature review and multidisciplinary expert panel discussion and provides a management framework for practicing thoracic surgeons.