LAUSR

W e lead a working group of the European Association for Cardio-Thoracic Surgery tasked to consider guidance to members on malignant pleural mesothelioma. We are mindful of the need to reflect all the evidence and therefore we appreciate publication of the series of 527 extrapleural pneumonectomy (EPP) operations.1 We also appreciate the recognition of the Mesothelioma and Radical Surgery (MARS) trial in providing background to the report.2 The scene is set in the introduction by quoting a median survival of 7 to 12 months, but this may be misleading. The unwary reader3 might hold these survival figures in mind as a comparator for the overall survival after EPP. The majority would never have been surgical candidates; patients who might have been candidates for surgery were specifically excluded by protocol from the cited trial of pemetrexed. On the contrary, among patients in a large published data set of 945 patients under consideration for possible surgery, there was no survival difference between those not operated on (N = 387; 41%) and those who had an exploratory thoracotomy without resection (N = 174; 18%) and was similar to those who had resection without other modalities of treatment (N = 177; 19%).4 All 3 groups survived an average of 17 to 18 months. Longer survival was recorded for the 22% who had adjuvant treatments, the effect of which will have played a part in survival. The sequen-