When evaluating a patient with MPM for surgical resection one must take into account the stage, functional status, and the surgical procedure. While pleurectomy/decortication may be the procedure of choice for patients with poor functional status and early-stage disease, the presence of lung parenchyma limits the amount of radiation that may be administered. In the majority of cases, an EPP is also required to obtain complete gross removal of tumor. The study by Rusch et al (10) shows that high-dose hemithoracic radiation at a dose of 54 Gy can be administered to the entire hemithorax after EPP with an acceptable toxicity. This treatment regimen is associated with a very low risk of local recurrence. The few local recurrences in this study appear to have been failures at the margins of the radiation field, emphasizing the importance of including the diaphragm, costophrenic sulcus, and ipsilateral half of the mediastinum. It is notable that the radiation used at this dosage essentially eliminates the risk of tumor recurrence in the chest wall that is commonly seen in patients with MPM and previous thoracic incisions. This study is the basis of our standard of care at Memorial Sloan- Kettering Cancer Center, and our results clearly indicate that now the greatest challenge is preventing the development of metastatic disease. With recent improvements in systemic therapy, it is now possible to add preoperative chemotherapy to the treatment regimen of patients (19,20). Both single-institution and multicenter trials are currently in progress for testing the efficacy of induction chemotherapy, followed by EPP and adjuvant hemithoracic radiation. It is hoped that active chemotherapy agents including cisplatin, gemcitabine, and pemetrexed will enhance the results of the excellent local treatment now available with EPP and adjuvant radiotherapy by decreasing the risk of distant relapse.