EPP is a much more demanding procedure with morbidity rates as high as 60% [77] and mortality rates of 4-9% [11, 78, 79] . However, the pneumonectomy in EPP allows the use of high dose hemithoracic radiotherapy, and this combined treatment has been shown to reduce local recurrence and prolong survival in early disease [65] . As a result, as part of the trimodality approach to treatment with surgery chemotherapy and radiotherapy, EPP has arisen as the surgical treatment of choice, albeit without clear randomised controlled trial evidence [78] . In order to clarify this issue, a large randomized trial (Mesothelioma And Radical Surgery (MARS)) is underway [80] . In this trial, EPP is sandwiched between induction chemotherapy and radical radiotherapy. The control arm offers full active tri-modality therapy, although the surgery is limited to debulking surgery. In addition patients receive the same induction chemotherapy and are given radiotherapy to any drain or port sites.