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Dr. Raja M. Flores, Chief of Thoracic Surgery at Mount Sinai Medical Center, has specialized in thoracic surgery and mesothelioma for 23 years. In an interview, Dr. Flores told the MCA that his interest in mesothelioma stemmed from both his mentor and his ability to relate on a personal level to his patients, who often come from a blue collar background similar to his own.

Known as one of the best surgeons in the world for performing what’s known as a VATS lobectomy and other minimally invasive surgeries, Dr. Flores and his experience in diagnosing and treating mesothelioma has helped him learn some of the best ways to improve the prognosis for his patients.

Dr. Flores spoke more specifically with the MCA about these risk factors and treatments that lead more often to better patient outcomes.

Early Diagnosis

As is the case with any cancer, catching the disease as early as possible improves a patient’s prognosis. This is notoriously difficult with mesothelioma, which is caused primarily by asbestos exposure that takes anywhere from 50-70 years to cause cancerous cell growth. Based on Dr. Flores’ research in Libby, Montana, the less exposure to asbestos, the less likely it is for a susceptible patient to contract the disease. There are other lesser-known, more rare causes, such as erionite, radiation infection, and exposure with the simian virus 40 (SV40).

Minimally Invasive Surgery

According to Dr. Flores, when compared to a thoracotomy — which opens the chest wall — a more laparoscopic approach (such as a VATS lobectomy) leads to fewer complications and less time spent in recovery for the right candidate. The VATS technique however, which uses 3 small incisions, is used mainly for diagnosing rather than treating mesothelioma because it is not appropriate for removing an entire tumor.

Characteristics that make a patient a favorable candidate for minimally invasive surgery include:

  • Epithelial histology
  • Female gender
  • arlier stage
  • Left-sided tumors
  • Lack of smoking or asbestos exposure
  • Surgical characteristics:
  • Body habitus
  • Comorbidities
  • Dense adhesions
  • Presence of anatomic issues


Dr. Flores has found that women who are diagnosed at a similar stage as men and given similar treatments still have higher survival rates. According to Dr. Flores, in order to better understand why and improve prognosis for both genders, “differences in asbestos exposure, tumor biology, and the impact of circulating hormones on host response must be investigated.”

Evolving Standard of Care

While there is no true standard of care for mesothelioma, research and experience with the disease has improved the various treatment options available. One of Dr. Flores’ mentors, for example, helped develop and perfect the extrapleural pneumonectomy (EPP), an aggressive surgery where the lung, part of the diaphragm, and lining around the heart and lungs are removed.

Less aggressive options for appropriate candidates include pleurectomy/decortication (P/D), where only the lining and diseased parts of the lung are removed. This procedure has the same survival rate as the former, but comes with less risk and shorter recovery.

Multimodal therapy is also an option for resectable patients with mesothelioma. Hemithoracic radiation decreases the risk of local recurrence while chemotherapy decreases the risk of metastasis.

Future Treatment

Currently, surgery followed by radiation has produced the most favorable outcomes. In terms of future treatment and work being done to continue to improve prognosis, Dr. Flores notes trials that are evaluating radical resection chemotherapy, radiation, intracavitary chemotherapy, photodynamic therapy, and immunologic/biologic agents. There is also a focus on improving patient screening for diagnosing tumors early along with improving treatment strategies.

Dr. Flores optimistically states, “Malignant pleural mesothelioma remains difficult to diagnose and treat, but the arsenal of therapeutic strategies has turned this once uniformly fatal malignancy into a chronic illness for some patients with modest (but present) long-term survival.”