Perioperative Treatments in Pleural Mesothelioma: State of the Art and Future Directions.

Pleural Mesothelioma (PM) remains a challenging malignancy associated with asbestos exposure and characterized by poor prognosis. This review aims to consolidate recent findings on the efficacy of perioperative therapies encompassing chemotherapy, surgery, and emerging immunotherapy strategies. Current management strategies debate the role of surgery in early-stage patients, particularly due to the limited success of solitary treatment modalities and significant rates of postoperative complications. Retrospective studies indicate that multimodal treatment, incorporating surgical resection with perioperative chemotherapy, can enhance overall survival (OS), especially in favorable prognostic subsets. However, significant randomized trials, notably the MARS and MARS 2 trials, revealed that the addition of aggressive surgical strategies like extrapleural pneumonectomy (EPP) did not confer survival benefits and was accompanied by heightened morbidity. In light of persistent challenges, integrating perioperative chemotherapy-primarily with platinum-based regimens-has shown improved disease control outcomes. Neoadjuvant chemotherapy permits real-time assessment of tumor responsiveness, providing valuable clinical insights for surgical candidacy. The role of immunotherapy, particularly immune checkpoint inhibitors (ICIs), is also under active exploration, with preliminary results suggesting promising activity and manageable safety profiles. In conclusion, while current protocols primarily recommend surgery for a select group of patients, ongoing investigations into neoadjuvant approaches, adjuvant therapies, and novel immunotherapeutic strategies are crucial for developing effective, personalized treatment paradigms for PM. Future efforts should prioritize clinical trials that integrate these therapies within a structured multidisciplinary approach to optimize patient outcomes.