Written By: Karen Selby, RN, Last modified: April 5, 2021

What Are the Stages of Mesothelioma?

The stages of mesothelioma are based upon the size of tumors and how far they have spread. The location and size of tumors has a direct impact on the symptoms a person may feel.

People often wonder if they can determine their stage based on their symptoms. Unfortunately, the symptoms of mesothelioma are not strongly correlated with the stages.

One of the reasons mesothelioma tends to be diagnosed in a late stage is the fact that early stages of mesothelioma cause no symptoms. The cancer is small in early stages and does not affect the body the way larger, late-stage tumors do.

Cancer staging is a crucial part of malignant mesothelioma diagnosis and treatment. Pathologists use biopsy samples to complete tumor grading and differentiation. Oncologists use these results with imaging scans to determine the cancer stage and whether a patient is likely to benefit from treatments such as surgery.

The 4 Stages of Pleural Mesothelioma

Stage 1: The tumor is localized in the mesothelial lining of the lung and has not spread.

Stage 2: Mesothelioma cancer cells have entered nearby lymph nodes.

Stage 3: Tumor progression is evident in nearby organs and distant lymph nodes.

Stage 4: Cancer cells have spread, or metastasized, throughout the chest cavity and to other organs.

Dr. Jacques Fontaine video on malignant mesothelioma

Watch: Thoracic surgeon Dr. Jacques Fontaine explains the four stages of mesothelioma.

Stage 1 Pleural Mesothelioma

Early-stage malignant pleural mesothelioma has not spread beyond the lining of the lungs, and most treatment options are available at this stage.

  • Initially, tumor growth is within a single area.
  • Stage 1 mesothelioma prognosis and life expectancy are significantly better than those in later stages.
  • It is difficult to catch the cancer this early because people with this stage do not usually experience symptoms.

Symptoms: Most mesothelioma patients do not experience symptoms at stage 1. At this stage, tumors are too small to cause pain or breathing difficulties.

Treatment: Stage 1 mesothelioma is treated with surgery, chemotherapy and radiation therapy. This approach is called multimodal therapy. Major surgery to remove the cancer is usually the first line of treatment.

Life Expectancy: People diagnosed at this stage have the greatest chance of living longer with mesothelioma. Median life expectancy at stage 1 is 22.2 months with surgery.

Treatment Options for Early-Stage Mesothelioma Patients

Watch: Learn the treatment options for mesothelioma when the cancer is in its early stages.

Stage 2 Pleural Mesothelioma

Prognosis is generally favorable in stage 2 mesothelioma, and most treatment options are still available, but symptoms may be more noticeable.

Stage 2 mesothelioma
  • Stage 2 indicates that tumors are beginning to spread beyond the mesothelial lining and into nearby lymph nodes, known as N1 lymph nodes.
  • Tumors remain small enough to be removed by surgery, which positively impacts life expectancy for mesothelioma patients.

Symptoms: Symptoms of stage 2 pleural mesothelioma, such as difficulty breathing during exercise or a mild cough, may resemble the common cold. Peritoneal patients may lose weight or feel bloated. It is generally rare for symptoms to appear in stage 2. Symptoms usually arise in stage 3.

Treatment: Stage 2 mesothelioma is treated with surgery, chemotherapy and radiation therapy. The same multimodal approach to treatment used at stage 1 is also used in stage 2.

Life Expectancy: Those who respond well to aggressive treatment may live longer than three to five years. Median life expectancy at stage 2 is 20 months with surgery.

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    Stage 3 Pleural Mesothelioma

    Symptoms worsen in stage 3 mesothelioma, and treatment options may be more limited than earlier stages, but certain types of therapies can improve survival.

    • Once the cancer progresses to stage 3, it may have spread to several tissues, organs and lymph nodes in the same region of the body where it formed.
    • Some stage 3 patients qualify for surgery depending upon the size and location of tumors.

    Symptoms: Stage 3 pleural symptoms include difficulty breathing, dry cough, wheezing and chest pain. Peritoneal patients develop constipation or diarrhea, abdominal pain and bloating. Both mesothelioma types may experience weight loss, fever and night sweats.

    Treatment: Stage 3 mesothelioma is typically treated with chemotherapy because most stage 3 patients are ineligible for surgery. At that point, doctors offer palliative options to control pain, improve quality of life and extend survival. Stage 3 patients can join clinical trials to try new chemotherapy drugs and immunotherapies.

    Life Expectancy: Some patients who qualify for surgery can live for years with stage 3 mesothelioma. Median life expectancy at stage 3 is 17.9 months with surgery.

    Stage 4 Pleural Mesothelioma

    The fourth and final stage of pleural mesothelioma involves cancer in multiple areas of the body, limiting most treatment options to palliative care that reduces the severity of symptoms.

    • By stage 4, cancer has spread throughout the area where it first developed and possibly to other parts of the body. Cancer could be present in the liver, brain, bones or elsewhere.
    • Tumor-removing surgery is not used at this stage. Minimally invasive surgeries may be used to control symptoms.

    Symptoms: Stage 4 pleural symptoms include extreme difficulty breathing, trouble swallowing and severe chest pain. Peritoneal symptoms include constant digestive problems, swelling of the abdomen, bowel obstruction and difficulty breathing or swallowing. Both types may experience loss of appetite, weight loss, muscle weakness, nerve pain, night sweats, fever and fatigue.

    Treatment: Stage 4 mesothelioma is treated with chemotherapy and palliative care to ease pain, control symptoms and extend survival. Many stage 4 patients qualify for clinical trials testing chemotherapy and immunotherapy.

    Stage 4 Mesothelioma Treatment Options

    Watch: Learn the treatment options available to people with stage 4 mesothelioma.

    Life Expectancy: Some stage 4 patients have lived longer than a year with mesothelioma. Treatments such as immunotherapy and chemotherapy for mesothelioma patients help people live longer at this stage. Median life expectancy at stage 4 is 14.9 months or less with or without surgery.

    Metastasis in the Final Stage of Mesothelioma

    Metastasis means that cancer has spread to a distant body part from where it first developed. This only happens in stage 4, the last stage of mesothelioma.

    Unlike other cancers, mesothelioma tends to metastasize locally rather than distantly. Mesothelioma is more likely to spread throughout the body cavity where it originated – either the chest cavity or the abdominal cavity – rather than spread to distant body parts such as the brain.

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    Pleural Mesothelioma Staging Systems

    Three systems have been used to stage pleural mesothelioma: TNM, Brigham and Butchart.

    TNM Staging System

    TNM is the most widely used and accepted system for staging malignant pleural mesothelioma. The American Joint Committee on Cancer (AJCC) developed this system over eight iterations, and it has replaced the other staging systems. The AJCC stage is the same as the TNM stage.

    Doctors will also indicate staging in this system as clinical or pathological. The results from imaging tests and physical examinations determine the clinical stage. Surgeons define the pathological stage based on the results found during surgery.

    Brigham Staging System

    The Brigham system was developed at Brigham and Women’s Hospital in Boston by Dr. David Sugarbaker. It was created to help identify which pleural patients would respond best to mesothelioma surgery.

    Butchart Staging System

    The Butchart system was developed in the late 1970s by Dr. Eric Butchart. He created it to help doctors identify which pleural patients could handle aggressive treatment with surgery.

    Peritoneal, Pericardial & Testicular Mesothelioma Staging

    Malignant pleural mesothelioma (MPM) is the only type that has an officially adopted cancer staging system.

    Peritoneal Mesothelioma Staging

    A TNM staging system is in the works for peritoneal mesothelioma, but more data is needed to make it official.

    Many doctors already use this system to stage peritoneal patients, while some may still use a simpler approach that defines only an early stage and a late stage.

    Other doctors use the Peritoneal Cancer Index (PCI), a system that assigns a stage to many other abdominal cancers. The PCI determines a score based on tumor size in 13 different regions throughout the abdomen.

    According to a 2020 study published in Scientific Reports, the index is an accurate tool for predicting prognosis and a patient’s response to treatment. In this way, PCI helps doctors make clinical decisions and serves as a substitute for an official staging system.

    Pericardial Mesothelioma Staging

    There is no staging system for pericardial mesothelioma because it is incredibly rare. Less than 150 cases have been reported, and it hasn’t amounted to enough data to create a staging system.

    Up to 45 percent of cases are diagnosed after tumors have spread to regional lymph nodes, lungs and kidneys.

    Testicular Mesothelioma Staging

    There is no staging system for testicular mesothelioma either. Less than 100 cases have been reported.

    How Staging Affects Mesothelioma Treatment and Prognosis

    Staging is the biggest factor doctors consider when coming up with your treatment plan. They also consider your age and overall health, but the cancer’s stage mostly determines which mesothelioma treatments you’ll qualify for. Doctors will continue to re-stage your cancer as treatment or disease progresses.

    Doctors also use staging to help inform a patient’s prognosis. The extent of disease determines the likelihood of success with the treatments available to you. An earlier malignant mesothelioma stage typically relates to a better prognosis and more prolonged survival.

    Dr. Fontaine Video Thumbnail

    Watch: Dr. Fontaine explains how the stage of mesothelioma affects the treatment options.

    Surgery

    Early-stage mesothelioma tumors (stage 1 and 2) are small and haven’t spread far. This makes them easier to remove with surgery and easier to target with chemotherapy and radiation therapy. Immunotherapy is also more effective when tumors are small.

    Staging that allows for surgery as a treatment option is termed resectable staging and means doctors can perform major surgery to remove cancer during the first line of treatment. If staging results indicate that surgery is no longer an option, doctors refer to the outcome as non-resectable staging.

    Late-stage mesothelioma tumors (stage 3 and 4) have grown and spread to a point that removing them surgically becomes impossible without removing vital organs. In other words, surgery could be life-threatening for people with late-stage mesothelioma.

    Chemotherapy & Immunotherapy

    These treatments are available to patients at any stage of mesothelioma. They are more effective at reducing tumor size and halting tumor spreading at earlier stages, but they can still extend the survival rate for mesothelioma patients in late stages.

    Radiation Therapy

    While radiation therapy is available at any stage of mesothelioma, the application and outcomes differ between early and late stages.

    • Radiation therapy for early-stage mesothelioma is used to prevent local recurrence after surgery.
    • When used in late-stage mesothelioma, the goal is to shrink painful tumors growing into the chest wall. This provides significant pain relief.

    Clinical Trials

    The stage you are diagnosed at will not exclude you from participating in mesothelioma clinical trials.

    These trials are testing a variety of treatments for different stages of mesothelioma. Some trials are looking for early-stage patients, while others are looking for late-stage patients.

    Clinical trials offer access to new, innovative therapies for mesothelioma including immunotherapy. Ask your doctor about the trials you may qualify for based on your stage and diagnosis.

    Common Questions About the Stages of Mesothelioma

    What are the stages of mesothelioma?

    The stages of pleural mesothelioma are:

    • Stage 1: Early tumor growth occurs along the mesothelial lining of one lung.
    • Stage 2: Cancer has spread to nearby lymph nodes.
    • Stage 3: Tumors have invaded deeper tissues in nearby organs and distant lymph nodes.
    • Stage 4: Metastasis is present, and tumors have formed at distant sites in the body.
    Is stage 4 mesothelioma always terminal?

    Mesothelioma is considered a terminal cancer because it has no cure. Stage 4 mesothelioma, also known as end-stage cancer or late-stage cancer, is the most advanced form of the disease. Treatment can be painful and varies between patients, but remission is possible. Palliative treatment options, which can improve symptoms and quality of life, also are available.

    How does staging impact a mesothelioma diagnosis?

    Doctors use staging to develop mesothelioma treatment plans for a given diagnosis based on the extent of cancer progression. Physicians determine a patient’s mesothelioma prognosis by the stage of their cancer and their response to treatment.

    Which staging system is used to stage for pleural mesothelioma?

    The TNM staging system is the most commonly accepted method for pleural mesothelioma staging. The acronym TNM stands for Tumor Nodule Metastasis and measures the extent of tumor growth into organ tissues, lymph nodes and distant sites in the body.


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