Mesothelioma Stages

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Mesothelioma staging determines the extent of mesothelioma progression. Staging helps doctors diagnose and treat cancer. Pleural mesothelioma is the only type with a recognized staging system known as TNM. Stage 1 pleural tumors remain localized, and stage 4 pleural mesothelioma tumors have spread to other parts of the body.

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Thoracic surgeon Dr. Jacques Fontaine explains the difference between mesothelioma stages.
Thoracic surgeon Dr. Jacques Fontaine explains the difference between mesothelioma stages.

What Are the Four Stages of Mesothelioma?

Stages of Pleural Mesothelioma, based on the TNM Staging System:

  • Stage 1: Mesothelioma cancer cells are localized in the mesothelial lining. Surgery is an option.
  • Stage 2: Cancer cells enter lymph nodes. Surgery remains an option.
  • Stage 3: Cancer cells spread to nearby organs and distant lymph nodes. Surgery may be an option. Chemotherapy is more common at this stage.
  • Stage 4: Cancer cells have metastasized throughout or beyond chest or abdominal cavity. Surgery is no longer an option. Chemotherapy may improve life expectancy and ease symptoms.

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.

Staging is a key part of mesothelioma diagnosis and treatment. Doctors use cancer stage as a guideline when deciding whether a patient is likely to benefit from treatments such as surgery.

Stage 1 Mesothelioma

  • Initially, tumor growth is within a single area.
  • The prognosis and life expectancy of stage 1 mesothelioma is significantly better than 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.


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

Stage 2 Mesothelioma

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

Symptoms: Stage 2 pleural mesothelioma symptoms, 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 Mesothelioma

  • 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 Mesothelioma

  • 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.

Life Expectancy: Some stage 4 patients have lived longer than a year with mesothelioma. Treatments such as chemotherapy and immunotherapy 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

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 pleural mesothelioma. It has replaced the other staging systems.

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 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.


How Are Peritoneal, Pericardial & Testicular Mesothelioma Staged?

Pleural mesothelioma is the only type that has an officially adopted 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.

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 Your Treatment Plan

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.


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.

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 survival 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.

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Registered Nurse and Patient Advocate

Karen Selby joined in 2009. She is a registered nurse with a background in oncology and thoracic surgery and was the regional director of a tissue bank before becoming a Patient Advocate at The Mesothelioma Center. Karen has assisted surgeons with thoracic surgeries such as lung resections, lung transplants, pneumonectomies, pleurectomies and wedge resections. She is also a member of the Academy of Oncology Nurse & Patient Navigators.

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Last Modified October 4, 2019

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