Should the surgical decision be influenced by the diagnostic biopsy in mesothelioma?

Surgical resection is offered to some patients with malignant pleural mesothelioma (MPM), depending on fitness for surgery and apparent technical resectability of the tumor. Due to risk of surgery-related morbidity and mortality in patients with a fatal malignancy, life expectancy is also a primary consideration in the surgical decision. Prognosis is related to the stage and histological subtype of the disease, neither of which can be known with certainty prior to definitive pathological review of the tumor specimen. Therefore, radiology and pleural biopsy, respectively, are used to predict these prognostic factors and to determine potential benefit from surgical intervention. In this review, we discuss the current limitations of histologic subtyping using pleural biopsy as a preoperative predictor. In addition, we explore available and emerging non-histologic analyses of biopsy specimens to evaluate molecular biomarkers, predicted neoantigens and the immune microenvironment. In the context of novel biological and immune-based treatment strategies currently under investigation for mesothelioma, accurate prognostic and predictive information available from biopsy material will likely influence treatment strategy including the surgical decision.