A single-center experience in parenchyma-sparing surgical treatment of malignant pleural mesothelioma

The role of surgery in malignant pleural mesothelioma (MPM) remains controversial, particularly after the negative results of the MARS 1 and 2 trials. Lung-sparing cytoreductive procedures such as extended pleurectomy/decortication (eP/D) are increasingly adopted in high-volume centers, but real-world outcomes within multimodality pathways vary widely. This study analyzes our Institutional experience with parenchyma-sparing surgery in a trimodal strategy, focusing on perioperative outcomes, recurrence patterns, and survival, with particular attention to the prognostic impact of nodal status. We conducted a retrospective observational study including consecutive patients with epithelioid MPM who underwent eP/D with curative intent between 2010 and 2022 at a single tertiary Center. All patients were evaluated within a multidisciplinary framework and routinely received platinum-pemetrexed induction chemotherapy. Clinical, pathological, perioperative, and follow-up data were prospectively recorded. Survival was analyzed using Kaplan-Meier curves and Cox regression. A total of 102 patients were included. Median age was 65.9 years, and 75% were males. Most patients (90%) received induction chemotherapy and 70% completed full trimodality therapy. Median hospital stay was 14 days (IQR 10.3-19.0). Postoperative morbidity occurred in 52% of patients, with major complications in 13%; 30 day and 90 day mortality were 1 and 3%, respectively. Recurrence occurred in 72% of cases, predominantly locoregional. Median disease-free survival (DFS) was 11.7 months (IQR 7.9-18.7) and median overall survival (OS) was 28.0 months (IQR 14.8-48.8). Nodal metastasis was associated with significantly worse OS (34.4 vs 17.4 months, p = 0.004), whereas completion of trimodal therapy did not significantly affect DFS or OS. Lung-sparing cytoreduction within a structured multimodality pathway is safe and achieves survival comparable to major international series. Pathological nodal status represents the strongest prognostic determinant and may guide risk-adapted treatment strategies in the evolving era of multimodal therapy.