Stage IV Mesothelioma

Stage IV Mesothelioma Locations in the Body

At stage IV, tumors have spread throughout the chest cavity and possibly to distant organs. Surgery is generally not a treatment option at stage IV, and most treatments are palliative rather than curative. The goal of treatment is to help you live longer, reduce pain and improve symptoms.

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  • Most advanced stage.
  • Tumor growth and symptoms are intensified.
  • Curative surgery is ineffective.
  • Doctors offer supportive care to help with symptoms.

Stage IV is the most advanced stage of mesothelioma. By stage IV, cancer has spread to one or both sides of the body. It may have also spread to lymph nodes and several organs of the body, including the brain, prostate, spine or the lining of the heart.

For people diagnosed at this stage, doctors offer treatments that relieve symptoms and prolong life. Your outlook depends largely on the extent of cancer spread and how well you respond to treatment.

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Symptoms of stage IV affect the lungs and possibly other parts of the body because of tumor spreading. Stage IV mesothelioma may cause fever, night sweats, chest-wall pain, shortness of breath, tightness in the chest, fluid retention in the abdomen, abdominal pain, fatigue, anorexia and malaise (a generalized feeling of illness).

  • Fever
  • Night sweats
  • Chest pain
  • Shortness of breath
  • Tightness of chest
  • Fluid buildup in chest or abdomen
  • Abdominal pain
  • Fatigue
  • Weight loss
  • Anorexia and Malaise

Some patients suffer from cachexia, a syndrome involving weight loss, muscle atrophy, weakness, fatigue and appetite loss. Stage IV cancer can also cause problems with the blood, including thrombocytosis (high platelet count) and anemia (low red blood cell count).

Learn more about symptoms


Stage IV tumors have spread to the degree that complete removal with surgery is usually not possible. For this reason, chemotherapy and radiation therapy are used to slow cancer growth and reduce symptoms. Stage IV treatment aims to alleviate symptoms and extend life span. Traditional cancer treatments and supportive care help to prolong survival and improve quality of life.

The spread of tumors is usually too vast at stage IV for doctors to remove all growths, so they typically do not recommend curative surgery. Some patients, however, can benefit from less extensive surgical procedures. Surgeons can attempt to remove as much tumor mass as possible or target only problematic tumors to help patients breathe more comfortably and decrease pain.

Doctors often treat stage IV cases with chemotherapy. First, they typically perform a PET scan, which produces images that clearly show where the cancer has spread. Chemotherapy drugs can slow tumor growth and might shrink tumors in some cases. These results can alleviate symptoms and extend survival.

Doctors don't always treat stage IV mesothelioma with radiation therapy, but they may recommend the procedure depending upon your tumor growth and overall health. Radiation therapy at this stage might be able to reduce the size of tumors, which can lessen chest pressure, decrease pain and improve breathing.

Supportive care helps to relieve symptoms and improve quality of life. At stage IV, doctors may recommend pain medication, oxygen therapy and respiratory therapies to control pain and improve lung function. Supportive care that aims to relieve symptoms is called palliative care.

Learn more about treatment options

Palliative Treatments for Mesothelioma

Even though aggressive surgery is ineffective against a stage IV diagnosis, a variety of treatments can help keep mesothelioma in check or relieve pain and other symptoms.

Many people benefit from procedures that remove fluid buildup near the main tumor, which can cause pain, breathing difficulty and other problems. The name of this procedure depends on the location of your cancer:

  • Thoracentesis drains fluid from the chest
  • Paracentesis drains fluid from the abdomen
  • Pericardiocentesis drains fluid from around the heart

For these procedures, a doctor numbs your skin and inserts a thin, hollow needle into the area where fluid is collecting. Sometimes an X-ray or another imaging scan is used to pinpoint the best place to insert the needle. Once the needle is inserted, the doctor uses a syringe to draw out some or all of the fluid.

Draining the fluid often alleviates some bothersome symptoms, but the results are usually temporary. The procedure does not stop the buildup of fluid, so you may need to repeat the procedure again if symptoms return.

For people with pleural mesothelioma, a palliative treatment called pleurodesis may provide a long-term solution to fluid buildup. In this procedure, a doctor inserts a tube into the chest to drain the fluid. Next, the doctor puts chemicals into the chest tube, such as talc, the antibiotic doxycycline or a chemotherapy drug called bleomycin.

These substances irritate the linings of the lung and chest wall, causing the space between them — where the fluid collects — to seal together and prevent future buildup. Doctors typically leave the chest tube in place for several days after the procedure to drain any remaining fluid.

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Chemotherapy Options for Stage IV

The most commonly used chemotherapy regimen for stage IV mesothelioma combines two drugs: Cisplatin and pemetrexed. A landmark 2003 study confirmed this combination can help people achieve a median survival of 12.1 months — a marked improvement over the 9.3 month survival observed with cisplatin alone.

The drug combination also had a high response rate, with 41.3 percent of patients responding to treatment. Patients treated with cisplatin alone experienced a response rate of only 16.7 percent. The promising results from this study played a key part in making cisplatin and pemetrexed the gold standard of chemotherapy plans for pleural mesothelioma.

Although smaller studies have explored the effectiveness of other drug combinations, no randomized studies directly compare cisplatin and pemetrexed with other platinum-based chemotherapy regimens.

Other chemotherapy drugs used to treat stage IV mesothelioma include:

  • Carboplatin
  • Cyclophosphamide
  • Doxorubicin
  • Gemcitabine
  • Methotrexate
  • Mitomycin
  • Mitoxantrone
  • Oxaliplatin
  • Raltitrexed
  • Vinorelbine

Certain people in stage IV may qualify for mesothelioma clinical trials. Some clinical trials investigate the value of various treatment combinations for late-stage mesothelioma.

Some of the more successful drug combinations explored in clinical trials include:

  • Cisplatin and gemcitabine followed by mitoxantrone, methotrexate and mitomycin (median survival of 13 months)

  • Cisplatin and raltitrexed (median survival of 11.4 months)

  • Cisplatin and gemcitabine (median survival of 10 months)

  • Vinorelbine and oxaliplatin (overall survival of 8.8 months)

Ask your doctor if you might qualify for any mesothelioma clinical trials.

Get more information on clinical trials that are testing out cutting edge treatments that could improve a patient's life span.

Learn more about clinical trials

Complementary and Alternative Treatments

Many people with stage IV mesothelioma consider complementary and alternative medicine (CAM). Numerous long-term mesothelioma survivors have incorporated CAM therapies into their treatment plan. Certain complementary therapies are known to improve survival, ease symptoms, reduce treatment side effects and enhance quality of life.


Diagnosed with stage IV mesothelioma? Consider the following:

  • Get a second opinion from a mesothelioma specialist. Not all oncologists are experienced in treating mesothelioma. Work with a doctor who is.

  • Consider alternative and complementary treatment options. Make sure to discuss alternative therapies with your doctor first.

  • Your lifestyle choices and overall health can impact quality of life and how well you respond to treatment. Make healthy lifestyle choices and eat a diet high in vegetables and immune-boosting foods.

  • Take care of your mental and emotional health. Many cancer centers offer counseling to cancer patients for free.

  • Connect with other people facing mesothelioma. Patients and their caregivers are welcome to join the online monthly support group. It meets the second Wednesday of every month.

  • Resources are available to help people with late-stage mesothelioma. Reach out to a patient advocate now if you need assistance.

  • Make time for hobbies and activities that bring you joy or encourage relaxation.

  • Spend time with family and friends, and express your appreciation for their support.

Your treatment team will use one of three staging systems to confirm a stage IV diagnosis. According to the Butchart system, the oldest of the three, a mesothelioma enters stage IV when it spreads through the blood to distant organs such as the brain, bones or liver.

The Brigham staging system, a newer system that focuses on lymph node involvement and whether the cancer can be removed by surgery, uses the same criteria for a stage IV diagnosis.

But the most widely used system is the TNM staging system. It is much more specific than the other systems, describing several diagnoses doctors classify as stage IV. Like the Brigham and Butchart systems, the TNM system considers any cancer that has spread to distant organs stage IV.

The TNM system also classifies some mesotheliomas as stage IV even if cancer has not spread to distant sites. These diagnoses typically involve extensive local spread or spread to lymph nodes near the tumor or on the opposite side of the chest.

The TNM system classifies the following as Stage IV:

  • Mesothelioma that has spread to distant sites

  • Mesothelioma that has spread to the lining that coats the lung, diaphragm and mediastinum, as well as to at least one of the following:

    • More than one place in the chest wall, including the muscle or ribs

    • Through the diaphragm and into the lining of the abdomen

    • Mediastinal organs like the esophagus, trachea, thymus and blood vessels

    • The spine
    • The lining on the other side of the chest

    • Through the heart lining or into the heart

  • Mesothelioma that has spread to lymph nodes near the collar bone on either side of the chest or to the hilar or mediastinal lymph nodes on the side of the chest opposite the main tumor.

Despite minor differences between these staging systems, they all serve the same purpose: Predicting life expectancy and guiding treatment decisions.

Prognosis & Life Expectancy

At stage IV the cancer is likely to continue to spread, which can lead to respiratory failure or heart failure if tumors spread to the heart.

The median survival for stage IV mesothelioma is 12 months. A positive response to treatment can extend survival, and patients with good prognostic factors often live longer than average.

Mesothelioma is considered a heterogeneous cancer, meaning no two cases are the same. For this reason, survival statistics cannot predict how long someone with mesothelioma will live. Some people have particularly slow-developing mesothelioma, and some respond surprisingly well to treatment. People in otherwise good health regularly outlive the average prognosis.

Prognostic factors associated with better survival include:

  • Epithelial cell type
  • Good overall health
  • Younger age
  • Female gender
  • No signs of blood disorders

Additional Resources

Karen Selby is a registered nurse and a Patient Advocate at The Mesothelioma Center. She worked in several subspecialties within nursing before joining in 2009.

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  11. Kalmadi, S. et al. (2007, November 19). Gemcitabine and Cisplatin in Unresectable Malignant Mesothelioma of the Pleura: A Phase II Study of the Southwest Oncology Group (SWOG 9810). Retrieved from
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