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Society of Thoracic Surgeons 2026 Expert Consensus on Pleural Mesothelioma

From WikiMesothelioma — Mesothelioma Knowledge Base
STS 2026 Consensus on Pleural Mesothelioma
Expert consensus, not a randomized trial
Topic Detail
Publisher The Annals of Thoracic Surgery, 2026;122(1):3-21
Method 13 structured questions, modified Delphi, ≥75% agreement
Panel size 17 authors, international multi-institution
Evidence class Expert consensus — no formal GRADE grading
Surgical preference Lung-sparing resection favored over extrapleural pneumonectomy
Shared cause Asbestos exposure

Executive Summary

In 2026, an international panel convened by the Society of Thoracic Surgeons 2026 Expert Consensus on Pleural Mesothelioma published contemporary treatment recommendations for pleural mesothelioma (PM) in The Annals of Thoracic Surgery.[1] The 17-author panel developed 13 Population-Intervention-Comparator-Outcomes (PICO) questions and reached consensus statements through a modified Delphi process requiring at least 75% agreement across three voting rounds.[1] The document is the most current expert statement on how pleural mesothelioma should be diagnosed, discussed by a multidisciplinary tumor board, and — for the subset of patients where it is appropriate — operated on.[1]

Two things distinguish this page from a general overview of mesothelioma surgery. First, it summarizes what one specific, citation-pinned document says, with exact bibliographic identity: PMID 42019659, DOI 10.1016/j.athoracsur.2026.03.074, published electronically April 20, 2026.[1] Second, it is explicit about what the consensus does not claim — it is expert agreement developed by modified Delphi, not a randomized controlled trial, and it reports no formal GRADE (Grading of Recommendations Assessment, Development and Evaluations) evidence grading.[1] That distinction matters for patients and families trying to gauge how much weight a "consensus statement" should carry against trial data like CheckMate 743 or MARS 2.

At a Glance

The 2026 STS consensus on pleural mesothelioma, at a glance:

  • 17-author international panel — thoracic surgeons, pathologists, radiation oncologists, and medical oncologists from institutions including Kaiser Permanente, Mayo Clinic, Memorial Sloan Kettering, and Brigham and Women's Hospital.[1]
  • 13 PICO questions, modified Delphi process — consensus statements required at least 75% panel agreement over three voting rounds.[1]
  • Diagnosis requires adequate biopsy plus imaging — accurate diagnosis depends on adequate pleural biopsy specimens, with clinical evaluation including at minimum CT and PET imaging.[1]
  • Multidisciplinary tumor board is the decision-making standard — therapeutic decisions should be discussed by a board that includes thoracic surgeons with PM expertise.[1]
  • Pleurectomy/decortication favored over EPP — when resection is appropriate, P/D or extended P/D is strongly favored over extrapleural pneumonectomy.[1]
  • No formal GRADE grading reported — the consensus does not assign a formal evidence-quality grade to its recommendations.[1]
  • Surgery remains controversial and selection-dependent — the panel frames resection as appropriate for some patients, not a blanket recommendation.[1]
  • It is expert consensus, not a randomized trial — read alongside RCT evidence such as MARS 2 and CheckMate 743, not in place of it.[1][2]

Key Facts

Consensus element What the panel says Source
Diagnosis Adequate pleural biopsy specimens; at minimum computed tomography (CT) and positron emission tomography (PET) imaging STS 2026 consensus[1]
Decision-making Multidisciplinary tumor board including thoracic surgeons with PM expertise STS 2026 consensus[1]
Surgical approach Pleurectomy/decortication (P/D) or extended P/D strongly favored over extrapleural pneumonectomy (EPP) STS 2026 consensus[1]
Evidence class Expert consensus via modified Delphi; no formal GRADE evidence grading reported STS 2026 consensus[1]
Surgery's overall role Controversial and dependent on multidisciplinary patient selection — not a blanket recommendation STS 2026 consensus[1]

What Is the 2026 STS Expert Consensus on Pleural Mesothelioma?

The Society of Thoracic Surgeons published its expert consensus document on the multimodal treatment of pleural mesothelioma in The Annals of Thoracic Surgery in 2026, with an electronic publication date of April 20, 2026.[1] The consensus carries full bibliographic identity: PMID 42019659, volume 122, issue 1, pages 3-21, DOI 10.1016/j.athoracsur.2026.03.074.[1] It was authored by a 17-person international, multidisciplinary panel drawn from institutions including Kaiser Permanente, the University of California San Francisco, Mayo Clinic, the University of Arizona, Memorial Sloan Kettering Cancer Center, the Medical College of Georgia, Baylor College of Medicine, the Icahn School of Medicine at Mount Sinai, UCLA, Northwestern University, University Hospital Zurich, the University of Chicago, New York University Langone Health, and West Virginia University.[1]

The panel's stated purpose was to update management pathways for PM by reviewing contemporary literature and producing consensus recommendations "with an emphasis on surgical intervention."[1] To do this, the panel developed 13 Population-Intervention-Comparator-Outcomes (PICO) questions and conducted a comprehensive literature review for each. Consensus statements were then developed using a modified Delphi process — a structured, iterative method for building expert agreement — that required at least 75% agreement across three voting rounds before a statement was adopted.[1] This methodology is the same general approach used by other major specialty societies to produce consensus statements when randomized trial evidence is incomplete, as it is throughout much of pleural mesothelioma surgical management.

What Did the Expert Panel Agree On?

The consensus reached strong agreement on three practical points that shape how patients move through diagnosis and treatment.

On diagnosis, the panel agreed that accurate diagnosis depends on adequate pleural biopsy specimens, and that clinical evaluation should include, at a minimum, computed tomographic (CT) and positron emission tomographic (PET) imaging.[1] Undersized or inadequate biopsy material is a recurring problem in pleural mesothelioma diagnosis, and the panel's statement reinforces that imaging alone is not sufficient.

On decision-making, the panel agreed that therapeutic decisions should be discussed by a multidisciplinary tumor board that includes thoracic surgeons with expertise in PM treatment — not decided unilaterally by any single specialist.[1] This mirrors the multidisciplinary standard already established in the American Society of Clinical Oncology's 2025 guideline update.[3]

On surgical approach, the panel agreed that if surgical resection is deemed appropriate, it should be part of a broader multimodal treatment plan — not a standalone intervention — and that pleurectomy/decortication (P/D) or extended P/D is strongly favored over extrapleural pneumonectomy (EPP) as the resection approach.[1] That preference for the lung-sparing procedure over the more extensive one is consistent with the direction the field has moved since MARS 2 found that adding extended P/D and chemotherapy did not improve survival over chemotherapy alone, even in operable patients — evidence that has made surgeons more cautious about the more aggressive EPP option specifically.[2]

What Does the Consensus NOT Say?

The panel is explicit about the limits of its own document, and those limits are as important as its recommendations.

It is not a randomized controlled trial. The consensus statements were developed through structured expert agreement — a modified Delphi process — not through a randomized comparison of treatments in patients.[1] A statement that 75% or more of a 17-person panel agreed on a management principle is a different kind of evidence than a trial result like the CheckMate 743 finding that nivolumab plus ipilimumab extended median survival to 18.1 months versus 14.1 months with chemotherapy.[4]

It reports no formal GRADE evidence grading. Many clinical guidelines assign each recommendation a formal evidence-quality grade (such as GRADE) so readers can see how strong the underlying evidence is. This consensus does not report that kind of grading; the ≥75% agreement threshold is a process metric describing how many panelists agreed, not an assessment of evidence quality.[1]

Surgery is not a blanket recommendation. Even where the panel favors P/D over EPP, it frames the overall role of surgical resection as controversial and dependent on multidisciplinary patient selection — language that stops well short of endorsing surgery for every pleural mesothelioma patient.[1] The substantial population of patients who are not surgical candidates at all is a reminder that this consensus describes a framework, not a universal treatment path.

It is not individualized medical advice. The consensus is a management framework for practicing thoracic surgeons, not a recommendation for any specific reader. Whether it applies to a given patient's disease is a question for that patient's own multidisciplinary care team.[1]

How Does This Consensus Compare to Other Mesothelioma Treatment Guidelines?

The 2026 STS consensus does not stand alone — it joins a small set of major guideline documents that shape pleural mesothelioma care, and it is broadly consistent with them rather than contradicting them.

The American Society of Clinical Oncology's 2025 guideline update similarly frames systemic therapy and multidisciplinary decision-making as central to treatment, while recognizing surgical options for appropriately selected patients.[3] The European ERS/ESTS/EACTS/ESTRO guideline likewise positions systemic therapy as the standard for advanced disease, reserving more extensive surgery for carefully selected candidates.[5] Where the STS 2026 consensus adds something distinct is its direct, comparative surgical-approach language — explicitly favoring P/D over EPP — reflecting how the field's surgical thinking has shifted following trial results like MARS 2.[2]

None of these documents recommend surgery in isolation from systemic therapy. The CheckMate 743 trial established first-line nivolumab plus ipilimumab as standard treatment for unresectable pleural mesothelioma, extending median overall survival to 18.1 months versus 14.1 months with chemotherapy — the systemic backbone around which any surgical discussion, including this consensus, now sits.[4]

What Does This Mean for Patients Making Treatment Decisions?

For a patient or family member trying to understand "what does the newest expert guidance say, and should I have surgery," the STS 2026 consensus offers a useful starting point for a conversation — not a personal answer. It confirms that an accurate diagnosis requires adequate biopsy tissue and appropriate imaging, that the decision should go through a multidisciplinary tumor board rather than one clinician's opinion, and that if surgery is on the table, P/D-type procedures are currently favored over EPP.[1]

The most useful way to use this document is as a set of questions to bring to that multidisciplinary team: Was my biopsy adequate? Did my evaluation include both CT and PET imaging? Has my case been reviewed by a tumor board that includes a thoracic surgeon with mesothelioma-specific experience? If surgery is being considered, why P/D rather than EPP in my case? Because the consensus itself acknowledges it is not randomized evidence and offers no formal grading of certainty, those questions — and the answers a patient's own care team gives — matter more than the existence of the consensus alone.

What Compensation Options Exist for Pleural Mesothelioma Patients?

The strength or limits of a surgical consensus statement have no bearing on a patient's legal rights. Pleural mesothelioma is caused almost exclusively by asbestos exposure, and patients diagnosed with the disease — regardless of whether they are surgical candidates under this or any other framework — may be entitled to compensation for that exposure.

Several paths to compensation can often be pursued at the same time: Asbestos Trust Funds established by bankrupt manufacturers, civil litigation against solvent defendants, and, for eligible former service members, VA benefits tied to service-related exposure. Because every state sets its own statute of limitations, families are generally better served by exploring these options early rather than waiting for treatment decisions to be finalized.

Frequently Asked Questions

What is the 2026 STS consensus on mesothelioma? It is an international expert-panel consensus — developed using a modified Delphi process with at least 75% agreement across three voting rounds on 13 PICO questions — on the multimodal treatment of pleural mesothelioma, published in The Annals of Thoracic Surgery in 2026.[1]

Does the consensus recommend surgery? It favors pleurectomy/decortication over extrapleural pneumonectomy when resection is deemed appropriate, but it frames the overall role of surgery as controversial and dependent on multidisciplinary patient selection — it is not a recommendation for every patient.[1]

Is this consensus the same as a clinical trial? No. It is expert consensus developed through structured agreement among panelists, not a randomized controlled trial, and it does not report a formal GRADE evidence grading.[1]

What imaging does the consensus recommend for diagnosis? At a minimum, computed tomography (CT) and positron emission tomography (PET) imaging, in addition to adequate pleural biopsy specimens.[1]

Who wrote the STS 2026 consensus? A 17-author international, multidisciplinary panel of thoracic surgeons, pathologists, radiation oncologists, and medical oncologists, including lead author Jeffrey B. Velotta along with senior authors Valerie Rusch, Raphael Bueno, Harvey I. Pass, and Hedy L. Kindler.[1]

Does this consensus affect my right to compensation for mesothelioma? No. Compensation depends on documented asbestos exposure and diagnosis, not on which surgical framework applies to a patient's case. Trust fund claims, civil litigation, and VA benefits may all be available, and state statutes of limitations make exploring these options early worthwhile.

Quick Statistics

  • 17 authors — the size of the international, multidisciplinary panel behind the STS 2026 consensus.[1]
  • 13 PICO questions — the structured questions the panel developed and reviewed against the literature.[1]
  • ≥75% agreement — the modified Delphi threshold required across three voting rounds to adopt a consensus statement.[1]
  • No formal GRADE grading — the consensus does not assign a formal evidence-quality grade to its recommendations.[1]
  • P/D favored over EPP — the panel's stated surgical preference when resection is appropriate.[1]
  • 18.1 vs 14.1 months — median overall survival with nivolumab plus ipilimumab versus chemotherapy in unresectable pleural mesothelioma (CheckMate 743), the systemic-therapy context surrounding any surgical discussion.[4]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 Velotta JB, Roden AC, Rice J, Simone CB, Upadhyay B, Sood P, Miller DL, Ripley RT, Wolf A, Burt BM, Kim SS, Opitz I, Kindler HL, Pass HI, Hayanga JWA, Rusch V, Bueno R. The Society of Thoracic Surgeons 2026 Expert Consensus on the Multimodal Treatment of Pleural Mesothelioma. Ann Thorac Surg. 2026;122(1):3-21. PMID: 42019659. https://pubmed.ncbi.nlm.nih.gov/42019659/
  2. ↑ 2.0 2.1 2.2 Lim E, Waller D, Lau K, et al. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial. Lancet Respir Med. 2024;12(6):457-466. PMID: 38740044. https://pubmed.ncbi.nlm.nih.gov/38740044/
  3. ↑ 3.0 3.1 Kindler HL, Ismaila N, Bazhenova L, Chu Q, Churpek JE, Dagogo-Jack I, et al. Treatment of Pleural Mesothelioma: ASCO Guideline Update. J Clin Oncol. 2025;43(8):1006-1038. PMID: 39778125. https://pubmed.ncbi.nlm.nih.gov/39778125/
  4. ↑ 4.0 4.1 4.2 Baas P, Scherpereel A, Nowak AK, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743): a multicentre, randomised, open-label, phase 3 trial. Lancet. 2021;397(10272):375-386. PMID: 33485464. https://pubmed.ncbi.nlm.nih.gov/33485464/
  5. ↑ Scherpereel A, Opitz I, Berghmans T, et al. ERS/ESTS/EACTS/ESTRO guidelines for the management of malignant pleural mesothelioma. Eur Respir J. 2020;55(6):1900953. PMID: 32451346. https://pubmed.ncbi.nlm.nih.gov/32451346/
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