Mesothelioma Stages

Quick Summary

Doctors diagnose patients with malignant mesothelioma using a system of 4 stages. The 4 stages of mesothelioma help doctors create customized treatment plans for each patient. Pleural mesothelioma is the only type with an official staging system, whereas peritoneal mesothelioma is diagnosed as early-stage or late-stage.

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What Are the 4 Stages of Mesothelioma?

  • Stage 1: A mesothelioma tumor is confined to a single location and has not spread.
  • Stage 2: The tumor grows, causing the spread of mesothelioma cells throughout one side of the body.
  • Stage 3: The cancer spreads beyond its original location and enters the lymph nodes, attacking nearby organs and tissue.
  • Stage 4: The tumor growth is significant, and the cancer spread is impossible to control.

Pleural Mesothelioma Stages

Malignant pleural mesothelioma develops in the lining of the lung (pleura).

It is the only type of mesothelioma to have an official cancer staging system, the Tumor Node Metastasis (TNM) system.

Stages of pleural mesothelioma fall into 2 categories:

  • Early-stage mesothelioma patients (stages 1 and 2) may be eligible for surgery, the most effective form of mesothelioma treatment. Surgery is often combined with chemotherapy and/or radiation.
  • Later-stage mesothelioma patients (stages 3 and 4) may not be eligible for aggressive surgery. Instead, comfort-focused palliative treatments may be used to reduce symptoms and improve a patient’s quality of life.

Stage 1 Pleural Mesothelioma

Patients diagnosed with stage 1 mesothelioma have the highest chance of long-term survival and a much better overall prognosis.

Stage 1 Pleural Mesothelioma

  • Symptoms: Flu-like symptoms
  • Treatment Options: EPP and P/D
  • Median Survival Time: 21.2 months

Symptoms

Some patients with stage 1 mesothelioma experience mild, flu-like symptoms, but these symptoms are typically overlooked. In fact, mesothelioma is rarely diagnosed at stage 1.

Doctors can also misdiagnose early mesothelioma symptoms as the flu or pneumonia. For this reason, it is important to ask your doctor or oncologist about mesothelioma as a potential cause of your symptoms.

Treatment Options

Stage 1 mesothelioma patients may qualify to undergo aggressive surgeries like extrapleural pneumonectomy (EPP) and pleurectomy with decortication (P/D).

Both procedures aim to remove all visible signs of cancer to increase a patient’s life expectancy.

Prognosis & Overall Survival

Stage 1 pleural mesothelioma patients have a likely potential for survival of nearly 2 years or longer. Patients who undergo surgery have a median survival time of 21.2 months, according to the 8th edition of the TNM staging system.

Medical Overview: Stage 1 Mesothelioma

A stage 1 mesothelioma tumor is contained to the chest wall. It is only present on one side of the body and has not spread to nearby lymph nodes or distant organs.

Up until 2017, stage 1 mesothelioma was subdivided into stages T1a and T1b (for the tumor component). Since 2018, these substages have been combined into a single T1 category.

Combining the substages eliminated the distinction between tumors invading the parietal (outer) pleura OR tumors invading both the parietal and visceral (inner) pleura.

Stage 2 Pleural Mesothelioma

Patients diagnosed with stage 2 mesothelioma are typically still candidates for curative surgeries and have similar overall survival rates to stage 1 patients.

Stage 2 Pleural Mesothelioma

  • Symptoms: Fluid buildup in lungs
  • Treatment Options: EPP and P/D
  • Median Survival Time: 18.9 months

Symptoms

Stage 2 mesothelioma symptoms may begin as mild or moderate but become more severe as the cancer progresses.

Many patients diagnosed with this stage experience uncomfortable fluid buildup in the lung lining (pleural effusions).

Treatment Options

Patients with stage 2 mesothelioma are still candidates for aggressive surgery. Doctors may recommend EEP or P/D to remove visible tumors and slow the disease spread.

Prognosis & Overall Survival

Stage 2 pleural mesothelioma patients have a prognosis comparable to that of stage 1 mesothelioma patients. Stage 2 patients who undergo surgery have a median survival time of 18.9 months, according to the 8th edition of the TNM staging system.

Medical Overview: Stage 2 Mesothelioma

Stage 2 mesothelioma cancer cells still remain on one side of the body but have spread to other locations on that side of the lung and lung lining.

Tumors may also be present on the diaphragm. This change causes more discomfort and is usually noticeable.

The most significant difference between stages 1 and 2 is that the cancer cells have spread to lymph nodes in the chest cavity. Cancers that have reached the lymph nodes are much harder to treat.

Stage 3 Pleural Mesothelioma

Patients diagnosed with stage 3 mesothelioma have fewer available treatment options but may still qualify for surgery and therapies that slow tumor growth.

Stage 3 Pleural Mesothelioma

  • Symptoms: Chest pain, fever
  • Treatment Options: Palliative care
  • Median Survival Time: 14.3 months

Symptoms

Patients with stage 3 mesothelioma often experience more severe symptoms, including chest pain, increased difficulty breathing, and fever.

Treatment Options

Stage 3 mesothelioma patients are usually ineligible for surgery because their cancer has already spread too far.

In these cases, patients will be treated with chemotherapy and palliative therapies designed to help reduce symptoms and improve quality of life. Stage 3 patients who cannot undergo surgery may also benefit from clinical trials to test out emerging therapies like immunotherapy.

Your doctor can help you determine whether surgery is a realistic treatment option for you.

Prognosis & Overall Survival

Stage 3 pleural mesothelioma patients are likely to survive for just over 1 year on average. Stage 3 patients who undergo surgery have a median survival time of 14.3 months, according to the 8th edition of the TNM staging system.

Medical Overview: Stage 3 Mesothelioma

In stage 3 mesothelioma, the cancer cells have started to spread beyond the original site of the tumor in the pleura.

In this stage, the cancer may have spread to the lymph nodes, as well as other tissues and organs. One side of the chest is primarily affected.

Stage 4 Pleural Mesothelioma

Patients diagnosed with stage 4 mesothelioma have fewer available treatment options, and care is focused on improving quality of life and comfort.

Stage 4 Pleural Mesothelioma

  • Symptoms: Weight loss, difficulty swallowing
  • Treatment Options: Palliative care
  • Median Survival Time: 10.1 months

Symptoms

Extensive tumor growth causes severe symptoms such as coughing up blood and difficulty swallowing.

Other symptoms include night sweats, extreme weight loss, abdominal pain, and chest tightness.

Treatment Options

Stage 4 tumors cannot be surgically removed and they have spread too far throughout the body.

Chemotherapy and radiation therapy are often used to slow the growth of the cancer and reduce painful symptoms from tumors. Some stage 4 patients may be eligible for clinical trials.

Doctors typically turn to palliative treatment options for patients with stage 4 mesothelioma, which may include hospice care.

Prognosis & Overall Survival

Stage 4 pleural mesothelioma patients have a poor prognosis, with most only living for 8-12 months after diagnosis. Patients with stage 4 have a median survival of 10.1 months, according to the 8th edition of the TNM staging system.

Medical Overview: Stage 4 Mesothelioma

In stage 4 mesothelioma, malignant cancer cells may spread to the opposite side of the body and affect distant organs.

Tumors may be found throughout the body, including in the spine, liver, or brain.

Peritoneal Mesothelioma Stages

Malignant peritoneal mesothelioma develops in the lining of the abdominal cavity (peritoneum). Any cancer growth within the abdominal region endangers the numerous vital organs nearby.

There is currently no official staging system for peritoneal mesothelioma, so doctors loosely classify this type of cancer as either early-stage or late-stage.

Mesothelioma specialists may also use other terms (localized, distant, advanced, metastasized) to describe a peritoneal mesothelioma stage.

Peritoneal mesothelioma is much more treatable than its pleural counterpart, with cytoreduction with HIPEC now considered the standard of care for eligible patients with this cancer type.

Nevertheless, a mesothelioma specialist will decide if a patient is a good candidate for surgery.

Early-Stage Peritoneal Mesothelioma

Patients diagnosed with early-stage peritoneal mesothelioma have a good chance of long-term survival and are often eligible for curative surgical procedures.

In early-stage peritoneal mesothelioma, malignant tumors develop in the peritoneum’s lining but have not spread to any distant sites in the body. The most common symptoms of early-stage peritoneal mesothelioma are bloating (abdominal distension) and abdominal pain.

Early-stage patients may be eligible to undergo cytoreductive surgery with heated intraperitoneal chemotherapy (HIPEC).

This surgery involves removing visible tumors from the peritoneum and then applying HIPEC (heated chemotherapy) directly to the abdominal cavity to kill the remaining cancer cells.

“Following the cytoreduction with HIPEC, patients usually complete […] chemotherapy. That is the ideal setup from my perspective, and I think that is how people do the best.” 

– Dr. Paul Sugarbaker, Peritoneal Mesothelioma Specialist

Patients who undergo cytoreduction with HIPEC have a median survival time of 38 months, according to National Cancer Institute (NCI) data from 2006-2010.

Late-Stage Peritoneal Mesothelioma

Late-stage peritoneal mesothelioma describes cancer that has spread to other, more distant sites in the body. Signs of late-stage peritoneal mesothelioma include new-onset hernia, fever, and night sweats.

Limited treatment options are available for late-stage mesothelioma patients.

Instead, the goal of treatment is to improve patient quality of life through palliative care options. This can mean forgoing aggressive surgeries that require lengthy recovery periods or would put the patient at risk of death.

Stages of Rare Mesothelioma Types

Like peritoneal mesothelioma, both pericardial mesothelioma and testicular mesothelioma do not have official staging systems.

Only a few hundred cases have ever been reported for these mesothelioma types.

Pericardial Mesothelioma Stages

Malignant pericardial mesothelioma develops in the lining of the heart (pericardium).

If the pericardial mesothelioma remains localized (contained to one area), surgery to remove the lining of the heart (pericardiectomy) may control the spread of the disease and reduce symptoms.

Testicular Mesothelioma Stages

Malignant testicular mesothelioma affects the lining of the testicles (tunica vaginalis).

Less than 100 cases of this type of mesothelioma have ever been reported.

Since symptoms are nonspecific, early diagnosis of testicular mesothelioma is rare. Surgery to remove localized tumors may be possible.

More About Mesothelioma Staging Systems

Three different staging systems exist to help doctors classify a patient’s stage of pleural mesothelioma. The TNM system is the most common.

TNM Staging System

The American Joint Committee on Cancer (AJCC) developed the TNM system for staging pleural mesothelioma.

The TNM system stages mesothelioma based on:

  • Tumor: Whether the original tumors have spread
  • Node: Whether tumors have spread through the lymph system
  • Metastasis: Whether cancer has spread to distant areas in the body

Doctors use this system to make informed decisions about a patient’s treatment options and create personalized treatment plans.

Clinical vs Pathological Staging

Within the TNM staging system, cases of malignant pleural mesothelioma are assigned a clinical stage and/or pathological stage.

Did you know?

The clinical stage describes a patient’s stage before treatment, whereas a pathological stage represents a patient’s stage after surgery.  

Mesothelioma doctors use both clinical and pathological stages to determine a patient’s “best” stage. The best stage is a combination of information gathered from whatever existing information which is based on the availability of their clinical stage, pathological stage, or both stages.

A patient’s “best” stage is deduced according to Union for International Cancer Control (UICC) and AJCC guidelines.

Butchart Staging System

The Butchart system is the oldest staging system, developed by Dr. Eric Butchart in 1976. This system has 4 stages and can be useful for classifying the spread of a patient’s primary tumor.

Since the Butchart system was developed before modern imaging methods, it has become outdated.

Brigham System

The Brigham staging system was developed by the late Dr. David Sugarbaker at Brigham & Women’s Hospital in Boston.

With this system, doctors stage mesothelioma based on whether it can be treated with surgery and whether lymph nodes are affected.

Get the Right Treatment for Your Mesothelioma Stage

No matter what mesothelioma stage you are diagnosed with, working with a specialist at a mesothelioma cancer center can help you receive the best possible treatment results.

Veterans with mesothelioma can get treatment from mesothelioma specialists within the U.S. Department of Veterans Affairs (VA) health care system. In fact, many of the nation’s top mesothelioma specialists work with the VA and Veterans.

Top VA mesothelioma doctors include:

  • Dr. Avi Lebenthal

    Dr. Lebenthal is a pleural mesothelioma specialist at the Boston VA Health Care System in Boston, Massachusetts.

  • Dr. Eugene Choi

    Dr. Choi is a peritoneal mesothelioma specialist at the Michael E. DeBakey VA Medical Center in Houston, Texas.

  • Dr. Robert B. Cameron

    Dr. Cameron is a pleural mesothelioma specialist at the VA Medical Center in Los Angeles, California.

Visit the UCLA Health website to learn more about Dr. Robert Cameron.

Disclaimer

The Mesothelioma Veterans Center has no affiliation with and is not endorsed or sponsored by Dr. Robert B. Cameron. The contact information above is listed for informational purposes only. You have the right to contact Dr. Cameron directly.

The Mesothelioma Veterans Center helps veterans get connected with experienced mesothelioma doctors. Call us at (877) 450-8973 for help finding a mesothelioma specialist today.

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.

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