Mesothelioma staging is the process of determining how far your cancer has spread. The 4-stage TNM system classifies mesothelioma from localized tumors at stage 1 to widespread at stage 4. Staging helps your doctor recommend the best treatment plan to help you achieve the best outcome.
Learn more about mesothelioma, asbestos and the steps you can take to fight this disease.
Mesothelioma has 4 stages. The stages range from 1 to 4. Stage 1 is the earliest or least advanced mesothelioma stage. Stage 4 is the most severe and means tumors have spread far in the body.
The 4 Stages of Mesothelioma
Stage 1: Cancer is localized to a single site and hasn’t spread. Tumors are small and removable via surgery. Median survival is about 21 months.
Stage 2: Tumors can be seen in nearby tissues and possibly lymph nodes. Surgery is an option and chemotherapy can prevent spreading.
Stage 3: Cancer has spread more into nearby organs and structures. Chemo and immunotherapy can shrink tumors.
Stage 4: Tumors have spread to distant organs throughout the body. Tumor-removing surgery is no longer helpful, but systemic therapy can extend life.
Your mesothelioma stage describes where signs of the cancer can be seen in your body or how far it’s spread. Doctors use a system for pleural mesothelioma commonly called the TNM system, which stands for Tumor, Node and Metastasis. This system, commonly used for other cancers as well, classifies mesothelioma into 4 stages.
Stage 1 Mesothelioma
Tumors begin to form on the pleura.
Stage 2 Mesothelioma
Tumors begin to spread from original origin.
Stage 3 Mesothelioma
Tumors keep spreading on the pleura.
Stage 4 Mesothelioma
Tumors nearly encapsulate the lung.
Stage 1 Mesothelioma
Stage 1 mesothelioma is the earliest stage when cancer is localized or still at the site where it first developed. It’s most likely located on the lining of the chest cavity, called the pleura, or the lining of the abdominal cavity, called the peritoneum. It hasn’t spread to lymph nodes or distant organs.
Symptoms are usually mild or nonexistent, which makes early detection difficult. A mesothelioma diagnosis at this stage often has the best prognosis.
Characteristics of Stage 1 Mesothelioma
Cancer is localized to its original site
Symptoms are mild or nonexistent
Treatment options: surgery, chemo and radiation
Pleural mesothelioma survivor Daniel McCarthy was diagnosed at an earlier stage, making surgery an option for him. He tells us, “My wife is a nurse and noticed I was short of breath. She convinced me to see a doctor, and it basically saved my life.”
With early detection, aggressive treatments such as surgery and multimodal therapy offer the best chance of long-term survival. Seeking care from a mesothelioma specialist can help ensure you explore all available options.
At stage 2, mesothelioma has started to spread beyond its origin into nearby lung, diaphragm, cardiac or abdominal tissue. Symptoms such as mild chest pain, coughing, nausea, abdominal discomfort and shortness of breath may begin to appear.
Early-stage treatment remains aggressive, and multiple options are available. Multimodal therapy, which combines treatments like surgery, chemo and radiation, is often recommended. Clinical trials may offer additional opportunities.
Characteristics of Stage 2 Pleural Mesothelioma
Cancer has spread into nearby tissue
Symptoms such as cough or pain may be vague
Treatment options: surgery, chemo and radiation
Diagnosed with stage 2 pleural mesothelioma in 2020, survivor Cheryl Pilkington tells us her doctors were surprised. But she says she and her sister often played in plaster dust in her father’s foundry shop. They were unaware the dust also contained asbestos.
“They never suspected [pleural mesothelioma],” Cheryl shares. “A female who was not in any business where there was asbestos exposure. They were shocked when the biopsy came back, but only until they heard my history.”
Stage 3 mesothelioma means the cancer has spread further into nearby structures such as the chest or abdominal wall, esophagus or deeper into the diaphragm and abdominal organs. Symptoms become more noticeable, including persistent chest pain, vomiting, difficulty breathing and fatigue.
Characteristics of Stage 3 Mesothelioma
Cancer has spread to nearby organs and lymph nodes
Symptoms include chest or belly pain, fatigue and breathing difficulties
Treatment options: chemo, immunotherapy and palliative care
Often surgery isn’t an option at this stage. But chemo, immunotherapy and palliative treatments can help manage symptoms and slow disease progression. Some people may qualify for clinical trials testing new therapies.
Pleural mesothelioma survivor Russell Lamkins tells us, “When I was first diagnosed with stage 3 inoperable cancer, I was told I had a year to live. I figured I’d better hurry up and finish the projects I was working on. But now, my goal is to make it to the 10-year mark.”
Stage 4 is the most advanced stage of mesothelioma. Cancer has spread to distant organs such as the liver, brain or bones. Symptoms are severe and may include significant weight loss, extreme fatigue and breathing difficulties.
Characteristics of Stage 4 Mesothelioma
Cancer has spread to multiple sites or distant organs
Symptoms include severe fatigue, weight loss and respiratory issues
Treatment options: palliative care, immunotherapy and clinical trials
Treatment often focuses on palliative care, pain management and oxygen therapy. Some patients explore immunotherapy or clinical trials to extend survival. Nearly 53% of mesothelioma health care professionals we surveyed told us they recommend immunotherapy as a first-line treatment for patients with inoperable malignant mesothelioma.
Pleural mesothelioma survivor Andy A. shares with us that immunotherapy has improved his health following his diagnosis in 2010.
“I guess I’m an anomaly. I’m doing great right now. I really am. I don’t look like a Stage 4 cancer patient. I consider myself extremely lucky for a lot of reasons.”
Mesothelioma Symptoms By Stage
Mesothelioma symptoms are generally mild and easier to overlook in the early stages. In stages I and II, most people experience no symptoms or only nonspecific concerns, such as fatigue, chest pressure or abdominal discomfort.
As tumors develop in stages III and IV, more fluids accumulate, shortness of breath with exercise increases and chest pain worsens. Abdominal swelling, nausea or changes in bowel habits are also more apparent.
Early vs. Late Stage Mesothelioma Symptoms
Early versus late-stage mesothelioma symptoms progress and worsen from mild to severe. Some require intervention from a mesothelioma specialist to improve quality of life.
Early-Stage Symptoms (Stages 1 and 2)
Fatigue or reduced energy levels
Mild, unexplained chest pain or tightness
Occasional abdominal pain or fullness (peritoneal)
Occasional nausea (peritoneal)
Ongoing cough
Shortness of breath during exertion
Unexplained weight loss
Late-Stage Symptoms (Stages 3 and 4)
Abdominal swelling or pain (peritoneal)
Blood in sputum or hemoptysis
Diarrhea, vomiting or bowel obstruction (peritoneal)
Ongoing cough
Reduced appetite along with excessive weight loss
Severe chest pain or pressure
Severe fatigue that impedes day-to-day life
Severe shortness of breath even at rest
Sweats and fevers
During early mesothelioma, you may not have any symptoms, or they may come and go. If you’ve been around asbestos and notice any changes to your health, consult a mesothelioma specialist.
By stage 3 and 4, symptoms are severe and will significantly impact your quality of life. Your mesothelioma team can assist with palliative procedures and medications to improve breathing, manage fluid issues and improve comfort levels.
How Is My Mesothelioma Stage Determined?
Your doctor will use several tests, including physical examinations, blood work and biopsies, to determine the stage of your mesothelioma. Imaging scans also play a key role.
Stage Diagnostic Tests
Biopsy: Doctors remove a small tissue sample via needle or a camera-assisted thoracoscopy (chest) or laparoscopy (abdomen) to confirm your mesothelioma cell type, stage and treatment options.
CT scan: A computed tomography scan (chest, abdomen or pelvis) indicates your stage based on tumor size, location, fluid accumulation and potential invasion into surrounding tissue or lymph nodes.
Fluid cytology: Pleural or peritoneal fluid tested from drainage suggests mesothelioma, but doesn’t definitively stage it without biopsy of the tissue. It can help guide your treatment.
Lymph node evaluation: A lymph node evaluation through mediastinoscopy or endobronchial ultrasound, also known as EBUS, is a guided needle biopsy obtained from your airways.
MRI: This imaging scan takes an effective picture of your chest wall, diaphragm or intra-abdominal organs, helping your surgeon determine involvement across tissues, which could change the stage or surgical approach.
PET-CT: Positron emission tomography, or PET, adds fluorescence to a CT scan to light up areas in your body with active cancer cells to identify disease in areas such as lymph nodes that are harder to see.
Thoracoscopy/laparoscopy: Thoracoscopy (in the chest) or laparoscopy (in the abdomen) helps your surgeon to see directly into either cavity, remove or drain excess fluid and obtain biopsies.
The information doctors gain from these tests is then assessed using specific systems for the type of mesothelioma you have. The TNM system is the most widely used for pleural mesothelioma. Other mesothelioma types are staged using different ways of describing how cancer has spread. For peritoneal mesothelioma, for example, doctors use the Peritoneal Cancer Index.
Insight From a Mesothelioma Specialist
The way we determine the stage is with a CT or PET scan
The stages of pleural mesothelioma range from 1 to 4 and use the TNM staging system. Pleural mesothelioma is the only type of mesothelioma with an official staging system. TNM staging measures tumor size (T), lymph node involvement (N) and metastasis (M).
What the TNM Staging System Measures
Tumor: Measures the size and location of the primary tumor.
Node: Determines whether cancer has spread to lymph nodes.
Metastasis: Identifies if cancer has traveled to distant organs.
Because pleural mesothelioma is the most common type, most people with mesothelioma will have their cancer staged using the TNM system. The 4 stages of pleural mesothelioma describe how far the cancer has spread or the extent of metastasis to other parts of the body.
Mesothelioma stages directly impact prognosis. According to the Canadian Cancer Society, the average life expectancy ranges from 21 to 51 months after a stage 1 diagnosis to 8 to 12 months when diagnosed with stage 4 mesothelioma.
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Do All Types of Mesothelioma Have Staging Systems?
While pleural mesothelioma has a formal staging system, other types of mesothelioma don’t. Pericardial and testicular mesothelioma are difficult to stage. Doctors often make individual assessments for each patient based on whether their cancer is localized or advanced.
Staging Pericardial, Peritoneal and Testicular Mesothelioma
Pericardialmesothelioma: Doctors often rely on modified standard cancer indexes to describe tumor size and spread.
Peritonealmesothelioma: Frequently staged using the peritoneal cancer index.
Testicularmesothelioma: Sometimes staged using a modified TNM system.
Doctors often use the peritoneal cancer index to stage peritoneal mesothelioma. PCI scores range from 1 to 39, which directly correlate to prognosis. Patients with PCI scores higher than 30 have the lowest survival rates at 1, 2 and 5 years, while those with scores lower than 20 have the highest survival rates.
Some doctors use the Peritoneal Surface Oncology Group International’s modified TNM system to categorize other types into 3 stages. This system helps determine which patients are most likely to benefit from surgery. Testicular mesothelioma is also sometimes staged using a modified TNM system. This system includes an added value, “S,” for serum tumor marker levels.
Insight From a Mesothelioma Specialist
If a doctor refers to peritoneal mesothelioma as stage 3, it usually means tumors have spread throughout the abdominal lining and to nearby lymph nodes.
Dr. Daniel Landau, oncologist and medical director of Virtual Hematology at the Medical University of South Carolina
How Does My Mesothelioma Stage Affect My Treatment Options & Prognosis?
As mesothelioma progresses or moves from earlier stages to later stages, it can affect what treatment options are most likely to offer someone the best outcome. Typically, surgery and other aggressive therapies may be possible in stages 1 and 2. For stages 3 and 4, treatment often focuses more on slowing the disease and managing mesothelioma symptoms.
The Role of Staging in Treatment Plans
Stages 1-2: Surgery, chemo and radiation therapy are often treatment options.
Stage 3: Treatment focuses on slowing tumor growth using chemo and immunotherapy.
Stage 4: Care centers on improving quality of life through symptom and pain management, along with oxygen therapy.
Dr. Fontaine emphasizes the importance of personalized care. He tells us, “The mesothelioma patients I treat who are good candidates for surgery are usually in the early stages, when the cancer is confined to the lung lining, hasn’t reached the lymph nodes and hasn’t spread to other organs.”
For pleural mesothelioma, 5-year survival rates range from 7% to 24%, depending on the stage at diagnosis, according to the American Cancer Society. But mesothelioma survival rate data is based on cases diagnosed years ago and can’t predict individual outcomes. While the typical mesothelioma life expectancy ranges from 22.2 months at stage 1 to 14.9 months at stage 4, new and advanced therapies are extending survival.
Staging mesothelioma requires CT scans PET scans, according to a review published in the Journal of Clinical Medicine.
Assessing the correct stage informs doctors about a mesothelioma patient’s prognosis and life expectancy.
“This is crucial because you need to know the extent of the disease in your body in order to get the most ideal tailored treatment regimen; thus, all patients should have, at a minimum, a CT scan and PET scan to start with.”
Common Questions About Mesothelioma Stages
At what stage is mesothelioma diagnosed?
Mesothelioma can be diagnosed at any stage, from I through IV.
Answered By:Anna Nowak, internationally renowned asbestos researcher and mesothelioma advocate
How fast does mesothelioma progress?
Every individual’s mesothelioma progresses at a different rate. Some have very slow-growing diseases, and others grow more rapidly. Sarcomatoid mesothelioma usually progresses more quickly than epithelioid mesothelioma.
Answered By:Anna Nowak, internationally renowned asbestos researcher and mesothelioma advocate
Is stage 4 mesothelioma always terminal?
Mesothelioma is considered a terminal cancer because it has no cure. Treatment success varies between patients, but remission is possible. Palliative treatment options are also available and may improve symptoms and quality of life.
Should I get a second opinion about my stage or diagnosis?
Yes. Second opinions from mesothelioma specialists can confirm your stage and expand treatment options.
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Dr. Jacques Fontaine is a thoracic surgeon at Moffitt Cancer Center in Tampa, Florida, where he heads up the Mesothelioma Research and Treatment Center. He specializes in minimally invasive robotic surgery and aggressive surgeries for mesothelioma.
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