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Should Surgery Be Performed for Sarcomatoid Mesothelioma?

Sarcomatoid mesothelioma is widely recognized as the most aggressive and rare form of mesothelioma. Because of how quickly it spreads and how poorly it responds to treatment, surgery is often not considered a helpful option for most patients.

Still, recent research suggests that there may be limited situations where surgery could play a role. The decision is complex and depends heavily on the patient’s overall health, disease stage, and treatment plan.

Difficulty Treating Sarcomatoid Mesothelioma

Mesothelioma develops in the lining of the lungs and is most often linked to asbestos exposure. It is generally divided into three main types: epithelioid, biphasic, and sarcomatoid.

Among these, sarcomatoid mesothelioma is the least common and the most aggressive. It tends to spread quickly through the chest and surrounding tissues and is often resistant to standard treatments like chemotherapy and radiation.

Because of this behavior, patients with sarcomatoid mesothelioma typically have a shorter life expectancy than those with other cell types. In many cases, survival is measured in months rather than years.

Why is Surgery Not Recommended for Treatment of Sarcomatoid Mesothelioma

Surgery for mesothelioma is designed to remove as much visible tumor as possible. However, sarcomatoid mesothelioma often grows in a diffuse pattern, making complete removal extremely difficult.

Research has shown that surgical treatment does not consistently improve survival for patients with sarcomatoid disease. In fact, outcomes for surgery in this subtype are generally poor compared to other forms of mesothelioma.

For this reason, many clinical guidelines advise against surgery for sarcomatoid mesothelioma, especially when the disease is advanced or has spread widely.

What Recent Research Suggests

Although surgery is not typically recommended, newer studies have explored whether carefully selected patients might benefit from an aggressive, multi-step treatment approach.

One recent clinical study by Dr. Raphael Bueno and his team at Brigham and Women’s Hospital examined outcomes of patients with sarcomatoid mesothelioma who underwent a lung-sparing surgical procedure known as pleurectomy / decortication, where the lining of the lung and visible tumor are removed while the lung itself is preserved.

The study found that:

Surgery is not standard, but may feasible in selected cases, on carefully selected individuals and only at specialized centers.
Multimodal therapy is key and other modalities of treatment must be used. The study was conducted prior to the approval of immunotherapy for mesothelioma, so it doesn’t take into account benefits achieved through systemic immunotherapy treatments which could further help improve outcomes in sarcomatoid mesothelioma.

The Role of Multimodal Treatment

Today, doctors are more likely to consider a combination approach rather than surgery alone. This is often referred to as multimodal therapy.

Multimodal treatment may include:

Surgery in select cases
Chemotherapy before or after surgery
Emerging treatments such as immunotherapy
Supportive care to manage symptoms and maintain quality of life

Even in cases where surgery is considered, it is rarely used on its own. It is typically part of a broader treatment strategy aimed at controlling the disease rather than curing it.

Selection Criteria for Patients with the Sarcomatoid Subtype of Mesothelioma

One of the most important factors in determining whether surgery might be appropriate is patient selection.

Patients with better lung function and overall physical health tend to tolerate aggressive treatments more effectively. In some studies, individuals with strong pre-surgical lung capacity showed longer survival compared to those with weaker respiratory function.

Other factors doctors evaluate include:

Stage of the disease
Extent of tumor spread
Overall health and age
Ability to tolerate additional therapies

Even with these considerations, surgery remains controversial for sarcomatoid mesothelioma.

The Bottom Line

For most patients with sarcomatoid mesothelioma, surgery is not a standard or highly effective treatment option. The disease is usually too aggressive, and outcomes after surgery alone are generally limited.

However, in rare and carefully selected cases, surgery may be considered as part of a broader treatment plan that includes chemotherapy or other therapies.

Because every case is different, treatment decisions should always be made by a specialized mesothelioma care team with experience in managing this rare cancer type.

To discuss treatment options for your specific situation, including a potential surgical resection, contact our expert mesothelioma nurse.

Inside Mesothelioma Care: Dr. Jeffrey Velotta on Surgery and Treatment

Mesothelioma is diagnosed in roughly 2,000 to 3,000 Americans each year, making it one of the rarest and most technically demanding cancers in thoracic medicine. Dr. Jeffrey Velotta, a thoracic surgeon who leads the mesothelioma surgical program at Kaiser Permanente in Northern California, recently joined Belluck Law‘s podcast Raise Plow to discuss where treatment stands today, including its genuine advances, its unresolved controversies, and the practical realities patients and families face after a diagnosis.

Built on High-Volume Training

Dr. Velotta’s approach to mesothelioma was shaped at Brigham and Women’s Hospital under Dr. David Sugarbaker, long considered the field’s foremost authority. At its peak, the Brigham performed approximately 200 mesothelioma surgeries annually. Surgeons there saw dozens of patients in clinic each week and operated on five to six per week, a volume that simply does not exist at most hospitals. That depth of experience is not incidental to outcomes. Surgeons who encounter mesothelioma once or twice a year cannot realistically achieve the same mastery as those working in dedicated, high-volume programs. Dr. Velotta’s time there gave him both the technical foundation and the clinical perspective that now inform his work at Kaiser, where he co-leads a multidisciplinary tumor board alongside medical oncologist Dr. Jennifer Suga.

Evolution from Lung Removal to Lung Preservation

For decades, the extrapleural pneumonectomy (EPP) was the standard surgical option for eligible mesothelioma patients. The procedure removes the affected lung entirely, along with surrounding pleural tissue and, in some cases, portions of the diaphragm and pericardium. It is aggressive by design, intended to eliminate as much disease as possible in a single operation.

The field has since moved substantially toward pleurectomy and decortication (P/D), a lung-sparing procedure that strips away the cancerous pleural lining while leaving the lung intact. The clinical rationale is straightforward: preserving the lung lowers morbidity, reduces mortality, and improves the patient’s recovery trajectory. Dr. Velotta noted that he has not performed an EPP in several years, a reflection of how thoroughly practice norms have shifted at experienced centers.
Mesothelioma surgery of either type remains among the most technically complex procedures in modern thoracic medicine. Unlike the majority of thoracic operations, which are now performed minimally invasively, mesothelioma surgery still requires large open incisions. Surgeons must dissect tumor from the aorta, the esophagus, the heart, and the lung itself. The difficulty of this work amplifies the importance of receiving care from a team that performs it regularly.

A Trial That Divided the Field

The most contentious development in recent mesothelioma research is the MARS-2 Trial, a randomized controlled study that compared outcomes between patients treated with chemotherapy alone versus those treated with chemotherapy combined with surgery. The trial concluded that surgery did not improve survival and may have been harmful, a finding that led some oncology programs to move away from surgical treatment altogether.

Dr. Velotta and a significant portion of American thoracic surgeons have raised substantial methodological concerns with that conclusion. The trial enrolled patients indiscriminately, including individuals with advanced disease who would not typically be considered surgical candidates at experienced U.S. centers. The reported ninety-day surgical mortality in the study was approximately nine percent, a figure that Dr. Velotta noted stands well above the under-two-to-three percent mortality seen at high-volume programs. Applying results from a study with that kind of mortality rate to the broader practice of specialized centers is, in his view, an overreach. The controversy has not been resolved, but it has had real consequences, reshaping institutional policies and narrowing surgical access for patients who might genuinely benefit.

Combining Therapies for Better Outcomes

Dr. Velotta is direct about the limits of surgery as a standalone intervention. No surgeon credibly claims that removing tumor tissue alone will cure mesothelioma. The operative goal is to reduce the burden of disease as much as possible while setting the stage for additional systemic therapies.

At Kaiser, this translates into a sequential multimodal strategy. Patients who are candidates for surgery receive the procedure first, followed by chemotherapy regimens typically built around cisplatin or carboplatin combined with pemetrexed. Immunotherapy is incorporated for select patients, particularly those with more aggressive disease subtypes. Patients who complete the full sequence tend to achieve the longest survival. The integrated care model at Kaiser, where all treating physicians, hospitals, and nursing staff operate within a single coordinated system, helps ensure that patients move through each phase of treatment without the logistical fragmentation that can compromise outcomes at less connected institutions.

Emerging Intraoperative Approaches

Dr. Velotta is also exploring a newer intraoperative technique involving heated betadine, a solution with demonstrated tumoricidal effects on mesothelioma cells. The approach offers a potential advantage over heated chemotherapy, which has been associated with increased complication rates, while still targeting residual cancer cells at the surgical site. Long-term outcome data is still being gathered, but the technique represents the kind of incremental refinement that characterizes how the field continues to develop between major trial results.

The Financial and Legal Dimension

A diagnosis of mesothelioma carries consequences that extend well beyond the clinical. The disease is causally linked to asbestos exposure, a connection Dr. Velotta described as straightforward: there is a clear cause-and-effect relationship between asbestos and the development of mesothelioma. For most patients, the exposure occurred decades earlier in occupational settings, often without adequate warning or protection.

Treatment costs, travel to specialized centers, and the physical toll of aggressive therapy create significant financial strain for patients and their families. Because most patients face a prognosis measured in years rather than decades, proactive legal and financial planning is genuinely important. Compensation through asbestos trust funds and litigation can provide meaningful support during an extraordinarily difficult period, and Dr. Velotta acknowledged that pursuing that avenue is, from his perspective, a sensible and often necessary step.

The Clearest Takeaway for Patients

Mesothelioma care is at a genuine inflection point. Research is actively evolving, institutional practices differ substantially, and the debate over surgery’s role in treatment continues. Against that backdrop, the most consistent guidance from specialists like Dr. Velotta is straightforward: seek out physicians and centers that treat mesothelioma at high volume, and insist on a personalized treatment plan from a multidisciplinary team. The rarity of the disease means that general oncologists and community hospitals will rarely have the accumulated experience to navigate it well. Finding those who do can make the difference between adequate care and the best available care.

Watch the Full Interview with Dr. Velotta

A Cold Solution to a Painful Problem: Cryoablation After Mesothelioma Surgery

For people living with pleural mesothelioma, pain is a constant companion. It comes from the tumor pressing against the chest lining, from fluid accumulating around the lungs, and, for those who undergo surgery, from the operation itself. Managing that pain without creating new problems has long been one of the most difficult challenges in mesothelioma care.

Now, a new study from thoracic surgeon Dr. Jeffrey B. Velotta and colleagues points toward a technique that could change the post-surgical experience for mesothelioma patients: intercostal nerve cryoablation, or the temporary freezing of nerves between the ribs.

How the Procedure Works

The idea is straightforward even if the name isn’t. During surgery and specifically during a pleurectomy decortication (the lung-sparing procedure known as PD), surgeons apply a specialized probe to nerves running between the fourth and eighth ribs. The probe delivers extreme cold, temporarily disabling those nerves’ ability to transmit pain signals from the chest wall to the brain. Over time, the nerves recover on their own, so as the patient recovers from surgery and the pain subsides, the nerves also get back to normal.

The goal isn’t to eliminate pain medication entirely. It’s to reduce how much is needed. Opioids, while effective for pain control, also carry their own serious risks and side effects.

Why Reducing Opioids is Important to Patients

Opioid medications like oxycodone and hydromorphone can be highly effective at controlling severe post-surgical pain, but for mesothelioma patients, the side effects are especially problematic. Drowsiness, confusion, nausea, constipation, and breathing difficulties are all common. For someone already struggling with compromised lung function and physical weakness, these effects can delay or derail recovery entirely.

After major chest surgery, patients are expected to do breathing exercises, walk short distances, and participate in pulmonary rehabilitation relatively quickly. Heavy sedation from opioids makes that participation harder. It can extend hospital stays, increase the risk of complications, and in some cases lead to long-term dependence.

This is why researchers have been looking for “opioid-sparing” approaches: these are ways to keep patients comfortable while reducing their exposure to narcotic medications.

What this Research Study Found

The study followed 64 pleural mesothelioma patients who had surgery between 2015 and 2024. Of those, 22 received cryoablation during their procedure and 42 did not. The results were notable.

Patients in the cryoablation group used roughly 40% less opioid medication overall. Close to twice as many of them required no opioids at all during their hospital stay. Crucially, their reported pain scores were similar to those who received standard care, meaning they weren’t simply enduring more discomfort. And the procedure did not appear to cause additional complications or dangerous nerve-related effects.

The study’s authors were careful to note the limitations: 64 patients is a relatively small sample, and more research is needed before cryoablation becomes a standard part of mesothelioma surgery. Still, the signal is encouraging.

Pain Is More Than Physical

It’s worth remembering that pain in mesothelioma doesn’t only affect the body. Chronic discomfort disrupts sleep, erodes mood, heightens anxiety, and strains relationships. Caregivers who watch a loved one suffer often carry their own heavy emotional burden, feeling helpless when pain medication doesn’t seem to be enough.

Patients sometimes hesitate to report pain, not wanting to “complain.” But communicating honestly with the care team about pain, especially when it’s interfering with sleep, movement, or breathing, is essential. Pain management is not peripheral to cancer care. It is central to it.

Palliative care specialists, social workers, counselors, and support groups can all help patients and families navigate the emotional weight of this experience alongside the physical one.

No One-Size-Fits-All Answer

Even if cryoablation becomes widely available, it is not looking to replace the full pain management arsenal. It will be one piece of a larger picture. Pain after mesothelioma surgery varies widely depending on the disease stage and location, the type of procedure, a patient’s other health conditions, and individual pain tolerance. Most patients will still need a combination of approaches, which may include epidurals or nerve blocks, acetaminophen, gabapentin, physical therapy, breathing exercises, and targeted opioid use.

Cryoablation, if the research continues to support it, may eventually join that toolkit as a way to make the other pieces more manageable.

Questions Worth Asking Before Surgery

Patients preparing for mesothelioma surgery may want to discuss pain management directly with their surgical team ahead of time. Questions like: What methods will be used to control pain after the operation? Will nerve blocks or cryoablation be available? What side effects should I expect from the medications? How long does post-surgical pain typically last? These conversations can help patients and families feel more prepared, and may open the door to options they didn’t know existed.

The Bigger Picture

Mesothelioma research is advancing on multiple fronts simultaneously. Immunotherapy, surgical techniques, and now post-surgical pain management are all areas where new findings are gradually reshaping what’s possible for patients. A 40% reduction in opioid use after major chest surgery isn’t a cure, but for the person in the hospital bed it can represent a significant difference in how recovery feels and the subsequent pace of recovery itself.

Note: This article is based on a study published in the Journal of Thoracic Disease by Dr. Jeffrey B. Velotta and colleagues, examining intercostal nerve cryoablation in pleural mesothelioma patients.

Renowned Mesothelioma Nurse Specialist Joins Belluck Law

Belluck Law has expanded its mesothelioma and lung cancer team with the addition of a dedicated nurse specialist, reinforcing its commitment to helping clients access the best possible medical treatment.

The firm welcomed Mary Hesdorffer, RN, MSN, a nationally recognized expert in mesothelioma care, to provide hands-on medical guidance and patient advocacy. With decades of experience in thoracic oncology, she works directly with clients to help them better understand their diagnosis, explore treatment options, and connect with leading mesothelioma doctors and clinical trials.

Helping Mesothelioma Patients Navigate Treatment

For individuals diagnosed with mesothelioma or lung cancer, navigating treatment decisions can be overwhelming. Belluck Law’s integrated approach ensures clients receive both legal representation and personalized medical support.

The firm’s nurse specialist assists with:

Understanding complex diagnoses and treatment plans
Identifying top mesothelioma specialists and cancer centers
Facilitating and fast-tracking appointment-making
Accessing cutting-edge clinical trials
Avoiding delays in care

A More Comprehensive Approach to Mesothelioma Cases

By incorporating medical expertise into its legal team, Belluck Law continues to differentiate itself among mesothelioma law firms. This client-centered approach focuses not only on securing compensation, but also on improving health outcomes and quality of life.

As mesothelioma cases often involve urgent and highly specialized care, having a dedicated medical professional on staff allows the firm to better support clients at every stage, from diagnosis through treatment, and beyond.

Five-Year Study Confirms Lasting Benefits of Immunotherapy for Mesothelioma

Key findings

Five years after treatment, 14 percent of patients who received immunotherapy were alive, compared with 6 percent of those treated with chemotherapy.
Among patients with epithelioid mesothelioma, five-year survival reached 14 percent with immunotherapy versus 8 percent with chemotherapy.
For patients with non-epithelioid mesothelioma, five-year survival was 12 percent with immunotherapy and only 1 percent with chemotherapy.
Median overall survival was 18.1 months with nivolumab plus ipilimumab, compared with 14.1 months for chemotherapy.
Tumor response occurred in about 39 percent of patients receiving immunotherapy and 44 percent receiving chemotherapy.
Seventeen percent of immunotherapy responders still had an ongoing response five years later.

A newly released five-year analysis from the landmark CheckMate 743 clinical trial provides encouraging evidence that immunotherapy can produce long-term survival for some people with unresectable pleural mesothelioma. The study results, highlighted by oncology news outlet OncoDaily and published in the Journal of Clinical Oncology, show that a combination of two immune checkpoint inhibitors continues to outperform traditional chemotherapy over time.

Pleural mesothelioma is a rare cancer that develops in the lining of the lungs and is strongly associated with asbestos exposure. For many years, treatment options were limited and long-term survival was uncommon. The updated results from CheckMate 743 suggest that immunotherapy is helping to change that outlook for some patients.

Comparing immunotherapy with chemotherapy

The CheckMate 743 trial evaluated the combination of nivolumab and ipilimumab as a first-line treatment and compared it with the standard chemotherapy regimen of pemetrexed (Alimta) together with cisplatin or carboplatin. Researchers tracked patient outcomes for a median follow-up period of nearly 67 months, providing the longest observation period yet for a first-line immunotherapy approach in pleural mesothelioma.

Investigators reported that the immunotherapy combination continued to demonstrate a survival advantage. As the researchers wrote in the journal article, “nivolumab plus ipilimumab demonstrated continued overall survival benefit versus chemotherapy in all randomly assigned patients.”

At the five-year mark, 14 percent of patients who received the immunotherapy regimen were still alive. In contrast, only 6 percent of patients treated with chemotherapy reached that milestone. The hazard ratio for overall survival was 0.74, meaning the risk of death was reduced by roughly 26 percent in the immunotherapy group.

Survival differences by tumor type

Mesothelioma is often categorized by histology, or tumor type. The most common form, epithelioid mesothelioma, typically responds somewhat better to treatment than the more aggressive non-epithelioid forms.

In the updated analysis, patients with epithelioid tumors experienced a five-year survival rate of 14 percent when treated with nivolumab plus ipilimumab, compared with 8 percent among those who received chemotherapy.

The contrast was even more pronounced in patients with non-epithelioid disease. In this group, five-year survival reached 12 percent with immunotherapy but only 1 percent with chemotherapy. The hazard ratio for overall survival among these patients was 0.48, suggesting a substantially lower risk of death when the immunotherapy combination was used.

Median survival and long-term outcomes

Median overall survival, which reflects the point at which half of patients are still alive, was 18.1 months for those treated with nivolumab plus ipilimumab. Patients who received chemotherapy had a median survival of 14.1 months.

Although these figures may appear modest, they represent progress in a cancer that has historically been difficult to treat. Median survival does not represent an average life expectancy. Instead, it marks the midpoint of the survival curve. Many patients may live longer than that value, and some significantly longer.

The five-year survival rate seen with immunotherapy is particularly notable given the historically low rates of long-term survival in mesothelioma.

Tumor responses and durability

Initial response rates were relatively close between the two treatment approaches. About 39 percent of patients receiving nivolumab plus ipilimumab experienced tumor shrinkage, compared with 44 percent of those treated with chemotherapy.

However, the durability of those responses differed dramatically.

Among patients whose tumors responded to immunotherapy, 17 percent continued to show a response five years later. In the chemotherapy group, none of the responders maintained an ongoing response at the five-year mark.

This pattern suggests an important distinction between the treatments. Chemotherapy may produce faster tumor shrinkage in some patients, but immunotherapy appears capable of generating longer-lasting control in a subset of cases.

Investigating potential biomarkers

Researchers also explored whether certain blood-based indicators might help predict which patients benefit most from immunotherapy. One area of focus involved monocytic myeloid-derived suppressor cells, often abbreviated as M-MDSCs.

These immune cells are believed to interfere with the body’s anti-cancer immune response and may limit the effectiveness of immunotherapy. The study found that patients who had higher levels of M-MDSCs at the start of treatment tended to experience poorer overall survival when treated with nivolumab plus ipilimumab.

Specifically, the hazard ratio for overall survival was 1.25 among patients with higher baseline levels compared with those who had lower levels. Researchers emphasized that this analysis is exploratory and will require additional study before such markers could guide treatment decisions.

Accounting for treatment crossover

Another factor examined in the analysis involved patients who switched treatments during the study. About 24 percent of participants who initially received chemotherapy later went on to receive immunotherapy.

To better understand the true effect of starting immunotherapy first, investigators performed an adjusted statistical analysis that accounted for this crossover. After making that adjustment, the hazard ratio for overall survival improved to 0.64 in favor of nivolumab plus ipilimumab.

The adjusted analysis also reduced the estimated median survival for the chemotherapy group to 12.1 months, further emphasizing the benefit associated with beginning treatment with immunotherapy.

Safety findings remain consistent

The extended follow-up period did not reveal any new safety concerns. According to the study authors, “no new safety signals were observed” during the longer observation period.

Immune checkpoint inhibitors can still cause immune-related side effects, which may affect organs such as the lungs, liver, or thyroid. However, the safety profile reported in the five-year update was consistent with what had been observed earlier in the trial.

A meaningful step forward

In their concluding remarks, the investigators noted that the updated data show sustained, long-term clinical benefits from nivolumab plus ipilimumab when used as a first-line treatment for pleural mesothelioma. The survival advantage was observed regardless of tumor histology.

As a result, the findings further reinforce the role of the immunotherapy combination as a standard treatment option for patients with unresectable pleural mesothelioma.

For individuals and families facing this diagnosis, the results do not represent a cure. Still, the ability of a therapy to help a portion of patients live five years or longer is a meaningful advance in a disease where durable survival has historically been rare.

Ongoing research will continue to explore how immunotherapy can be improved, identify which patients benefit most, and determine how new treatment strategies might build on the progress already achieved.