**1. Introduction**

MPM is a rare tumor that has become a world health issue due to its poor prognosis and its increasing incidence, largely due to prior asbestos exposure (the latency is about 20–40 years). Median overall survival (OS) is approximately 1 year in patients with MPM, and the 5-year OS rate is about 10% [1]. In recent years, there has been a notable advancement in the comprehension of MPM pathogenesis, leading to new

promising drugs and therapeutic schemes [2, 3]. Particularly, recent trials including innovative drugs, such as targeted therapies or immunotherapies, have encouraged MPM patients [4]. Optimal treatment strategy in MPM has not yet been well established, consequently, current guidelines from the British Thoracic Society (BTS) [5], the American Society of Clinical Oncology (ASCO) [6], the National Comprehensive Cancer Network (NCCN) [1] and the European Society for Medical Oncology (ESMO) [7] have examined similar studies but reached different conclusions. Newly, a task force composed of the European Respiratory Society (ERS), the European Society of Thoracic Surgeons (ESTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Radiotherapy and Oncology (ESTRO) [8] proposed updated and practical guidelines on routine management of MPM, after a systematic review of the 2009–2018 literature, including new promising therapies and strategies. Up to the present, therapeutic strategies for MPM are still discussed; therefore, with a lack of a homogeneous consensus on this theme, physicians preferred to evaluate every single patient in a multidisciplinary team to adopt the best treatment based on the performance status of the patient and the stage of the tumor.

The current Eighth Edition of tumor, nodes, metastasis (TNM) classification for MPM [1] is reported in **Tables 1** and **2**. As stated in the aforementioned guidelines, at early stages (disease confined to the pleural envelope, without N2 lymph node involvement) with favorable histology (epithelial), a surgical approach with curative intent in a multimodal protocol appears to be indicated to enhance survival and quality of life. Instead, in advanced stages with distant spread palliative or supportive care must be preferred.

Because of the diffuse growth pattern and the lack of surgical margins, microscopic complete resection is theoretically impossible. Thus, a MCR should be the aim of the surgery, even though the optimal cytoreductive procedure is still controversial [9, 10]. There are two main surgical options to obtain MCR—EPP and PD; the superiority of one technique over the other is still debated [11]. Due to the high morbidity, both surgical techniques should be achieved only in tertiary referral centres with a wide experience in thoracic surgery [12]. Generally, surgery achieves only cytoreduction, hence it must be associated with induction CT (iCT) or adjuvant CT (aCT) with or without adjuvant RT (aRT) to achieve better outcomes in terms of survival and control of the disease.

The best combination of these different therapeutic approaches is still a matter of debate [13, 14]. Hence, the aim of this up-to-dated literature review is to provide a complete overview of the current surgical approaches to MPM, discussing within the frameworks of pre-operative diagnostic evaluation and multimodality oncological treatments.
