Purpose of reviewMalignant mesothelioma is a uniformly fatal disease and active supportive care, minimizing patient morbidity, remains the accepted standard treatment. Tract metastases in patients with mesothelioma are a well recognized complication of pleural intervention and prophylactic radiotherapy is commonly implemented to prevent their occurrence. This review critically analyzes the published literature to establish the role of prophylactic radiotherapy to pleural puncture sites and highlights controversies that exist.Recent findingsCurrent practice is based on a clinical study published in 1995. However, two recent randomized controlled trials did not support the widely held belief that all patients undergoing diagnostic or therapeutic pleural puncture should receive prophylactic drain site irradiation. Data assessing the incidence of associated morbidity from tract metastases suggest that rates are lower than previously thought.SummaryThe routine administration of radiotherapy in all patients with mesothelioma following pleural intervention remains debated. Instead of prophylactic irradiation, directing surveillance toward patients with large (e.g. thoracoscopic) pleural puncture sites and reserving treatments to symptomatic deposits may be more appropriate. This strategy would optimize patient care and minimize hospital visits, but allow prompt instigation of treatment if symptoms develop.