Biphasic Mesothelioma

Quick Summary

Both epithelioid and sarcomatoid cells are present in biphasic mesothelioma. The prognosis of biphasic mesothelioma depends on how many cells are epithelioid and how many cells are sarcomatoid. More epithelioid cells correspond to more treatment options and a better prognosis.

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Understanding Biphasic Mesothelioma

Epithelioid cells grow faster, but they stick together. This stops the cells from spreading quickly. Sarcomatoid cells spread to other organs faster than epithelioid cells. About 1/3 of mesothelioma patients have a biphasic cell type.

Pathology of Biphasic Mesothelioma

It is important for the pathologist to identify both kinds of cells. They can estimate how many of the cells are epithelioid and how many are sarcomatoid. The more epithelioid cells visible under the microscope, the better the patient’s prognosis. The cells are more likely to have already metastasized if more cells are sarcomatoid.

Signs and Symptoms of Biphasic Mesothelioma

Symptoms alone aren’t always enough to cause suspicion of mesothelioma. Doctors may suspect mesothelioma if there is a known history of asbestos exposure.

Typical signs and symptoms in biphasic patients include:

  • Chest or abdominal pain
  • Shortness of breath
  • Fluid around the heart, abdomen or pleural space
  • Unexplained weight loss
  • Unexplained fever
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Diagnosis of Biphasic Mesothelioma

The diagnosis of biphasic mesothelioma begins with imaging tests. Doctors may order X-rays or CT scans of the abdomen and/or the chest. PET scans are sometimes done to locate metastases. In a PET scan, the patient is given radioactive glucose. Cancer cells absorb this substance faster than healthy cells. The scan then detects the areas where the radioactive material gathered.

Doctors will take a biopsy if imaging scans revealed potential tumors. There are several possible biopsy procedures. Thoracoscopy and mediastinoscopy take tissue samples from the chest. Laparoscopy takes tissue from the abdomen. Most biopsies use a camera placed through a small incision to locate tumors.

Pathologists are specialists in identifying cell types. A pathologist will examine your biopsy under a microscope. If the diagnosis is difficult, the pathologist may use immunohistochemistry. This procedure uses special stains that attach to certain cell types. This can help pathologists distinguish between an epithelioid and biphasic cell type.

“It is often difficult to draw the line between epithelioid mesothelioma and biphasic mesothelioma[…],” the authors of a 2017 study said. “However, separation of biphasic mesothelioma from epithelioid mesothelioma is important because therapeutic option and prognosis are different between two subtypes of mesothelioma.”

Diagnosing biphasic mesothelioma can be difficult. Biopsy samples only observe a small piece of a tumor at a time, while epithelioid and sarcomatoid cells may be far apart on a biopsy sample. Pathologists may misdiagnose biphasic mesothelioma if they only see one cell type under the microscope.

Larger samples give a better view of the overall cell landscape and can help pathologists make a more accurate diagnosis. However, If the doctor doesn’t suspect biphasic mesothelioma, large samples may never be collected.

In some mesothelioma cases, people only find out they have biphasic mesothelioma after surgery. Surgery provides the best access possible to many tumors, and surgically removed tumors are often collected and analyzed to reconfirm a patient’s diagnosis.

After your doctor makes a concrete diagnosis, he can prescribe the most appropriate treatment for you.

Treatment of Biphasic Mesothelioma

Biphasic mesothelioma treatment is highly individualized. The stage of your disease is also important. Stage 1 and 2 patients with more epithelioid cells often get surgery, chemotherapy and radiation. In stage 3 and 4, the disease may already have spread too far throughout the body. If it has spread too far, potentially curative surgery cannot be performed. These patients may have palliative surgery to reduce symptoms or to have a better quality of life.

Patients with more sarcomatoid cells aren’t usually eligible for surgery. But doctors may consider some patients in earlier stages for surgery.

Did you know?

There are newer treatments out there for patients with biphasic therapy. Some of these include intensity-modulated radiation therapy, photodynamic therapy and gene therapy.

Those with more sarcomatoid type cells get traditional chemotherapy and radiation. Treatment may also focus more on investigational therapies.

Getting the correct diagnosis can help determine which treatments will be more effective. Get a second if you want to make sure your diagnosis is correct. You can also join a clinical trial. These trials offer experimental therapies to patients who qualify.

Here are some potential treatment options for advanced biphasic mesothelioma:

  • Traditional chemotherapy with Alimta and cisplatin
  • Immunotherapy with checkpoint inhibitors for tumors that cannot be removed by surgery.
  • Targeted therapy with bevacizumab to cut off tumor growth
  • Surgery to drain fluid from the chest, improving quality of life
  • Pleurectomy with decortication as a way to relieve symptoms
  • Radiation therapy to shrink tumors and relieve pain
  • Clinical trials with combinations of chemotherapy, radiation and experimental therapies
  • Cytoreduction to remove tumors in the abdomen
  • Chemotherapy sent to the chest or abdominal cavity to prevent fluid buildup and shrink tumors

Prognosis of Biphasic Mesothelioma

The prognosis of biphasic mesothelioma depends on the ratio of epithelioid to sarcomatoid cells. The average life expectancy of a patient with biphasic mesothelioma is 8-21 months. Those who have more epithelioid cells often live longer.

Next Steps for Veterans with Biphasic Mesothelioma Cell Types

The first step for veterans with biphasic mesothelioma is to confirm their diagnosis. It’s possible that your doctor missed something. Or maybe he gathered a biopsy from an area higher in sarcomatoid cells. It’s important to ensure that your treatment is correct for the cancer cells in your body. You can always request your pathology report, have your doctor explain your diagnosis or seek a second opinion.

Main aspects of a biphasic mesothelioma diagnosis:

  • Biphasic mesothelioma contains epithelioid and sarcomatoid cells.
  • Patients with more epithelioid cells have a better prognosis.
  • A specialist needs to determine the best treatment options for you.

It is the right of every patient to get a second opinion. You’ll find that good doctors will encourage you to get another opinion. You can ask a mesothelioma specialist within the VA or look elsewhere if you were diagnosed at the VA.

Second opinions can present you with new treatment options. If the second diagnosis shows less sarcomatoid cells, you could have new treatment options. Your doctor may also give you a better prognosis. But second opinions are mostly about peace of mind. Learn more about second opinions.

Veterans Support Team
Todd Gersten, MD PhotoReviewed by:Todd Gersten, MD

Double Board-Certified Oncologist and Hematologist

  • Fact-Checked
  • Editor

Todd Gersten, MD is a double board-certified medical oncologist and hematologist specializing in general adult oncology and hematologic disease. He is a physician partner with the Florida Cancer Specialists and practices in Wellington, Florida.

Dr. Todd Gersten is an independently paid medical reviewer.

Christopher Dryfoos PhotoWritten by:

Contributing Author

Christopher Dryfoos is a journalist and member of the American Medical Writers Association (AMWA). As the grandson of the U.S. Navy’s first forensic pathologist, he aims to help veterans with mesothelioma access needed care.

View Sources

American Cancer Association. “Early Detection, Diagnosis, and Staging.” 2016. Retrieved from: Accessed on August 21st, 2017.

National Cancer Institute. Accessed August 21st, 2017.

Hiroshima, Kenzo. Journal of Thoracic Oncology. “P3.03-013 BAP1 Immunostaining and FISH Analysis of p16 Help Making Distinction among Subtypes of Mesothelioma.” 2017. Retrieved from: Accessed on August 22nd, 2017.

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