Mesothelioma types indicate where tumors form in the body. Each type causes different symptoms and requires personalized treatment. Knowing whether the cancer is pleural, peritoneal, pericardial or testicular helps ensure you get care tailored to your needs and the best possible outcome.
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Dr. Andrea Wolf: What are the different types of mesothelioma?
Mesothelioma is a disease or a cancer of the lining of compartment of the body. So in the peritoneum, that's the abdomen.
In the pleura, which is my specialty.
Plural mesothelioma comes in sort of two general varieties. Meaning based on the histology, which is what the pathologist looks at under the microscope.
There is something called epithelial cell type, which is a little more favorable, associated with a better survival and more common. And there's something called sarcomatoid mesothelioma, which is, a little bit more difficult to treat and patient have a worse prognosis.
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Dr. Andrea Wolf: What are the different types of mesothelioma?
Mesothelioma is a disease or a cancer of the lining of compartment of the body. So in the peritoneum, that's the abdomen.
In the pleura, which is my specialty.
Plural mesothelioma comes in sort of two general varieties. Meaning based on the histology, which is what the pathologist looks at under the microscope.
There is something called epithelial cell type, which is a little more favorable, associated with a better survival and more common. And there's something called sarcomatoid mesothelioma, which is, a little bit more difficult to treat and patient have a worse prognosis.
What Are the 4 Types of Mesothelioma?
Mesothelioma has 4 main types, based on where the cancer starts in the body. All types begin in the mesothelium, a thin layer of tissue that covers organs and body spaces. The different types occur with varying frequency.
The 4 Types of Mesothelioma
Pleural mesothelioma: This type forms in the lungs’ lining (pleura). Pleural mesothelioma accounts for 75% to 80% of all cases.
Peritoneal mesothelioma: This type starts in the abdominal lining (peritoneum). Peritoneal mesothelioma accounts for 10% to 20% of cases.
Pericardial mesothelioma: This rare type develops in the heart’s lining (pericardium). Pericardial mesothelioma accounts for 1% of all cases.
Testicular mesothelioma: This is the rarest type and forms on the lining of the testes (tunica vaginalis). Testicular mesothelioma accounts for less than 1% of cases.
Each type of mesothelioma leads to distinct symptoms and treatment paths. Asbestos exposure can damage cells in the mesothelium and turn them into cancer. But there are also benign (noncancerous) and indolent (slow progression) variants, such as well-differentiated papillary and multicystic mesothelioma, with more favorable outlooks.
Dr. Andrea Wolf, director of the Women’s Lung Cancer Program at Mount Sinai, tells us, “Pleural mesothelioma comes in two general varieties. There is something called ‘epithelial cell type,’ which is a little more favorable. It’s associated with better survival and is more common. And there’s something called ‘sarcomatoid mesothelioma,’ which is a little bit more difficult to treat and patients have a worse prognosis.”
Pleural Mesothelioma
Pleural mesothelioma is a cancer that starts in the lining of the lungs. It makes up most mesothelioma cases, about 75% to 80%. If you have chest pain, trouble breathing, tiredness, fever or weight loss, see a doctor. Finding it early can lead to better treatment. Doctors use exams, scans, fluid tests and a biopsies to diagnose it. Be sure to tell your doctor if you’ve been exposed to asbestos.
Diagnosis: Imaging such as X-rays and PET/CT scans identify tumors. Biopsies confirm mesothelioma and specific cell types.
Survival: Median survival ranges from 12 to 21 months depending on stage and cell type.
Symptoms: Chest pain, cough, shortness of breath and pleural effusion (fluid buildup).
Treatment: Includes surgery such as pleurectomy/decortication, chemotherapy or immunotherapy.
Doctors often treat early-stage pleural mesothelioma with immunotherapy, chemotherapy (platinum + pemetrexed), surgery and radiotherapy. People treated in stage 1 may live around 3 years or more, while stage 4 patients usually live about 12 months. However, pleural mesothelioma survivors who have lived for decades after their diagnosis and treatment have shared their firsthand stories with us. Each person is an individual. Clinical trials also offer new treatment options and have helped people achieve better outcomes.
Experience From a Mesothelioma Survivor
“If we remain in denial about our condition or allow doubt and fear to rule our decision-making, it will undermine our treatment plan. Anger, cynicism, anxiety and depression can drastically affect our ability to continue on a path to recovery. Mesothelioma treatments can be tough, and things may look bad, but there is hope. Don’t give up!”
Michael Cole, 10-year pleural mesothelioma survivor
Peritoneal Mesothelioma
Peritoneal mesothelioma starts in the lining of the belly, which protects your stomach and other organs. This type of mesothelioma makes up about 10% to 30% of all cases. Common symptoms include belly pain, swelling, bloating, loss of appetite and changes in bowel habits. If you notice any of these signs, talk to a doctor for help and advice.
Diagnosis: CT scans or MRIs identify tumors and spread. Biopsies of tissue or fluid confirm mesothelioma and identify the cell type.
Survival: Median survival is about 53 months for patients who receive aggressive treatment.
Symptoms: Abdominal pain, swelling and weight loss.
Treatment: Cytoreductive surgery combined with heated intraperitoneal chemo or HIPEC.
Doctors often treat peritoneal mesothelioma with a combination of surgery and heated chemotherapy. About 50% of patients can get this treatment, and many of them live 5 years or longer after diagnosis. Even though people with peritoneal mesothelioma usually have a better outlook than those with pleural mesothelioma, doctors still need to do more research to improve care. Some doctors use immunotherapy combinations, but that treatment is not FDA-approved.
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Pericardial mesothelioma is a rare type of cancer that grows in the sac that protects the heart called the pericardium. Doctors have only reported about 200 cases. People with this very rare cancer might feel chest pain, have an irregular heartbeat, cough a lot or have trouble breathing.
Diagnosis: Echocardiogram, PET/CT, and MRI help locate pericardial tumors. Biopsies are required to confirm mesothelioma.
Survival: Because it’s often diagnosed at an advanced stage, median survival is typically 6 to 10 months.
Symptoms: Chest pain, difficulty breathing and palpitations.
Treatment: Multimodal approaches with surgery, chemo and immunotherapy are common.
Doctors may treat pericardial mesothelioma mostly with surgery and chemo. A 2022 report in the Journal of Thoracic Oncology showed patients who got a mix of these treatments lived a median of 25.9 months. Those who received both types of treatment, called bimodal therapy, lived a median of 70 months. To choose the best treatment for you, talk with your doctor about every option.
Testicular Mesothelioma
Testicular mesothelioma is a very rare cancer that starts in the outer lining of the testes or tunica vaginalis. Doctors have reported fewer than 300 cases, which accounts for fewer than 1% of all mesothelioma cases.
Diagnosis: Ultrasound imaging and biopsy.
Survival: Recent research shows around 49% of patients live 5 years or more, with outcomes improving with early treatment.
Symptoms: Swelling of the scrotum or lumps.
Treatment: Surgery is the primary treatment.
People with testicular mesothelioma may notice swelling in the scrotum or painless lumps. Doctors often treat it with surgery and chemotherapy. Some patients may also join clinical trials to try new treatments. With these options, many people live for more than 2 years after diagnosis.
How Doctors Diagnose and Confirm Mesothelioma Type
Specialists use a step-by-step process to diagnose mesothelioma. They then classify your mesothelioma type according to location and subtype according to the kind of mesothelioma cells found.
Initial suspicion and imaging: CT scans, PET/CT and MRI help locate tumors and assess how far they’ve spread in your body.
Biopsy and pathology: Tissue samples are analyzed under a microscope to identify cancer cells.
Immunohistochemistrymarkers: Tests for specific proteins that are signs or markers of mesothelioma like calretinin, WT-1 and D2-40 differentiate mesothelioma from other cancers, helping to confirm a diagnosis.
Second-opinionpathology review: Getting a second opinion with a pathologist experienced with mesothelioma can help ensure an accurate diagnosis.
If you have questions or concerns about your pathology report, a Patient Advocate can assist you. Your Patient Advocate can also arrange a second opinion with a pathologist who specializes in mesothelioma. You usually don’t need a new biopsy. Pathologists can review your existing slides to confirm your diagnosis and cell type.
Research into liquid biopsy techniques, including circulating tumor DNA and circulating tumor cells, shows promise for less invasive diagnosis in the future. Consulting a mesothelioma specialist and working with patient advocates ensures optimal diagnostic accuracy and access to the latest treatments.
Mesothelioma Cell Types
In addition to the 4 main types of mesothelioma, there are 3 subtypes based on cell types. These subtypes differ in aggressiveness and how they respond to different treatments. Identifying cell types allows doctors to better predict tumor behavior, treatment response and outcomes.
Epithelioid: The most common and favorable type. This subtype makes up about 70% to 75% of all cases. Cells form clusters, making diagnosis easier. Typically respond best to surgery and combination therapies. Median epithelioid pleural survival is 18–24 months.
Sarcomatoid: Rarest and most aggressive form. This is the least common among mesothelioma subtypes, making up about 10% to 20% of all diagnoses. Cells are spindle-shaped and less responsive to traditional treatments, although some respond well to immunotherapy.
Biphasic: Contains both epithelioid and sarcomatoid cells. About 30% of pleural tumors and 25% of peritoneal tumors are classified as biphasic. Prognosis depends on the proportion of each. More epithelioid cells often means better outcomes.
Tumor plasticity means mesothelioma cells can change from one type to another, which can make treatment more difficult. For example, someone with epithelioid mesothelioma may develop biphasic mesothelioma if some cells become sarcomatoid. Rare variants such as desmoplastic, lymphohistiocytoid and deciduoid mesothelioma also exist, each with its own cell structure under the microscope.
Dr. Andrea Wolf explains, “If there’s more than 90% of one cell type, it’s referred to as ‘pure’ of that cell type. So somebody with more than 90% epithelioid cell type under the microscope is considered epithelial. But if there is a representation for both cell types, that’s called biphasic or mixed cell.”
[MUSIC PLAYING] The two main cell types, meaning the types of cells the mesothelium could be made up of, when we look at it under the microscope, are epithelial and sarcomatoid. And these are jargon-like terms, but they become important in terms of the prognosis of the patient and how we treat the disease. So the epithelial cell type is a little more common, and the patients with that disease have a better prognosis. The sarcomatoid cell type is a little more difficult to treat, and that disease behaves a little differently. It tends to progress locally, meaning it doesn’t tend to metastasize or go to other places, but it can go through the chest wall and cause pain or go under the diaphragm and affect the abdomen. Now if somebody has more than 90% of either of those cell types, we consider their disease that cell type. If they have more than 10% of both, we call it mixed or biphasic. And generally speaking, we tend to divide groups when we look at information about patients with mesothelioma as epithelial and non-epithelial, with the non-epithelial including sarcomatoid, mixed subtype, and a few other very rare ones. Even though patients with non-epithelial disease do have, overall, a worse prognosis, that doesn’t impair long-term survival. I published a paper about 11 years ago showing that patients with non-epithelial disease can still live three years or more. People shouldn’t take the prognosis associated with their cell type as a hard and fast rule about how long they’re going to live. [MUSIC PLAYING]
What Are the Three Subtypes of Mesothelioma
[MUSIC PLAYING] So these three subtypes of mesothelioma– again, the sarcomatoid, the mixed, and the epithelial– have different clinical courses, if you will. They express themselves within the patient in a different manner. And it’s important to understand which one of these three the physician is dealing with in any particular patient. And that’s because each tumor, such as sarcomatoid, is a very, very aggressive tumor that needs aggressive therapy and needs it more urgently than the other two types. The mixed type of tumor also has a more aggressive clinical course. And we find that, again, in this situation, we need to act more urgently and more aggressively. Now, the epithelial subtype of mesothelioma, again, while it is epithelial mesothelioma, and as one here is the term “mesothelioma,” obviously, we are still moving forward in an urgent fashion. Nevertheless, our options for therapy are greater because it’s been shown that this cell type does, indeed, respond to more of a variety of treatment strategies. [MUSIC PLAYING]
Epithelioid Cells
Epithelioid mesothelioma cells often look like ovals or cubes and tend to clump together, which helps doctors spot them under a microscope. These cells usually grow slower and respond better to treatment than other types.
Mesothelioma specialists take cell types into account when they develop a treatment plan with you. The aim is to match you with the therapy option that will fight your specific type best. The responsiveness of epithelioid mesothelioma to treatment is good news for patients, as those with epithelioid cell tumors often have a better outlook.
Treatment Response
Best results with surgery, chemotherapy, and immunotherapy
Prognosis
Median survival 18–24 months, generally most favorable
Sarcomatoid Cells
Sarcomatoid mesothelioma cells are long and spindle-shaped, like stretched-out ovals. You might hear this cell type referred to as sarcomatous, spindle or diffuse malignant fibrous mesothelioma. It’s also known as the most aggressive cell type.
These cells often grow in loose patterns instead of clumps. This makes sarcomatoid mesothelioma harder to treat, as the cells spread quickly through the body and respond poorly to most treatments.
Treatment Response
Poor overall response to traditional therapies, some benefit from immunotherapy
Prognosis
Shorter survival; aggressive disease course
Biphasic Cells
Biphasic mesothelioma has a combination of epithelioid and sarcomatoid cells. The cancer’s behavior depends on which cell type is more dominant in the tumor. Tumors with more epithelioid cells tend to grow slower and respond better to treatment. When sarcomatoid cells are dominant, the cancer is often harder to treat and more aggressive.
People with biphasic mesothelioma often have a better outlook if a tumor has more epithelioid cells. But as Dr. Wolf tells us, “People shouldn’t take the prognosis associated with their cell type as a hard and fast rule about how long they’re going to live.”
Treatment Response
Variable; dependent on cell proportions
Prognosis
Intermediate; more epithelioid means better outlook
Treatment by Type of Mesothelioma
When developing your mesothelioma treatment plan, your doctor will consider your mesothelioma type and cell type. This is why a precise mesothelioma diagnosis is such a key part of developing a personalized treatment plan. Your doctor will also consider your age, overall health and treatment goals.
Type
Primary Treatments
Pleural
Surgery, chemotherapy, immunotherapy
Peritoneal
Cytoreductive surgery, HIPEC, chemotherapy
Pericardial
Surgery, chemotherapy, palliative care
Testicular
Surgery, chemotherapy
A multimodal or combined therapy approach has been shown to usually yield the best results for mesothelioma survivors. If you’re younger and in good health, surgery might be a good choice. Many patients can also benefit from chemo, radiation or immunotherapy. Treatment plans are tailored based on mesothelioma type and stage. The following table summarizes common therapies.
FDA-approved immunotherapy combinations include Keytruda (pembrolizumab) with chemo and Opdivo (nivolumab) with Yervoy (ipilimumab). New palliative options also improve quality of life.
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Chemo treats several types of mesothelioma. For pleural mesothelioma, doctors often use a mix of cisplatin and Alimta (pemetrexed). This combination slows the growth of tumors and improves symptoms.
For peritoneal mesothelioma, doctors may use drugs like Gemzar (gemcitabine) or Paraplatin (carboplatin). Paraplatin is sometimes heated and placed directly into the abdomen during heated intraperitoneal chemotherapy or HIPEC.
In our exclusive 2025 survey of mesothelioma survivors, participants who reported remission were 31% more likely to have received Paraplatin than those who didn’t.
Surgery
Doctors use different surgery options for mesothelioma depending on where the cancer starts. Surgery works best for younger patients in good health who catch the disease early. Some surgeries are targeted, removing only tumors and affected tissue, while others are more aggressive.
For example, pleurectomy and decortication for pleural mesothelioma only removes tumors and the lung lining. But an extrapleural pneumonectomy removes an entire lung. During a peritonectomy for peritoneal mesothelioma, tumors and sometimes part or all of nearby organs like the stomach, intestines, liver, pancreas or spleen are removed. A pericardiectomy for pericardial mesothelioma removes the sac around the heart, and an inguinal orchiectomy for testicular mesothelioma removes the affected testicle.
Insights on Surgery Options for Pleural Mesothelioma Patients
Pleural Mesothelioma Stage
Percentage of Patients Opting for Surgery
Stage 1
20%
Stage 2
22%
Stage 3
14%
Stage 4
11%
Source:
The Mesothelioma Center at Asbestos.com, 2025
Immunotherapy
In 2024, the FDA approved the immunotherapy drug Keytruda (pembrolizumab) in combination with the chemo drugs Alimta and Platinol or Paraplatin as a first-line treatment for pleural mesothelioma. This followed the agency’s 2020 approval of Opdivo (nivolumab) and Yervoy (ipilimumab) together as a first-line therapy for pleural patients.
Today, immunotherapy for pleural mesothelioma is an established treatment with positive results. While not specifically FDA-approved as a first-line treatment for other mesothelioma types, some specialists are seeing benefits of this therapy for their patients.
Radiation Therapy
Doctors often combine radiation with surgery to slow tumor growth in people with pleural mesothelioma. Radiation therapy on its own can shrink tumors and relieve symptoms, helping many patients feel better. However, radiation is less common for other mesothelioma types because of safety concerns and limited data.
Radiation isn’t commonly used for peritoneal mesothelioma because it might affect organs like the kidneys or liver. It’s also uncommon for pericardial mesothelioma because of the potential risk of damage to the heart. There’s less data to support radiation for testicular mesothelioma, making its use less common than for pleural patients, though radiation may still be part of a multimodal treatment plan for this type.
Insight From a Mesothelioma Specialist
“Radiation therapy can be used with other types of mesothelioma treatment, including chemotherapy or surgery.”
Sean Marchese, oncology medical writer and registered nurse
Palliative Therapy
Palliative therapy controls the pain and other symptoms cancer can cause. It plays an important role in your treatment plan and can improve how you feel and live.
One common palliative treatment for mesothelioma is thoracentesis, where doctors drain excess fluid around your lungs to help you breathe more easily. Another helpful option is paracentesis, which removes fluid from your belly to ease pressure and make eating more comfortable. These treatments can help you feel better and enjoy a better quality of life.
A 2024 report says peritoneal patients in a study had a lower overall response to Keytruda than pleural mesothelioma patients did. This highlights the role mesothelioma type can play.
Individual factors also matter. The 2024 report discusses a peritoneal patient who is 4 years disease free following 2 years of Keytruda. Discuss your options with your doctor.
“The type of mesothelioma a patient has plays a critical role in determining the best approach. Treatment options can vary significantly based on tumor type and characteristics, which is why patients need to understand how their medical team tailors recommendations to their specific diagnosis rather than applying a one-size-fits-all approach.”
Common Questions About the Types of Mesothelioma
How does the type of mesothelioma impact prognosis and treatment?
The type of mesothelioma a patient has impacts their overall prognosis and recommended treatments. Mesothelioma treatment is complex, and many other factors influence treatment options and prognosis, such as the stage of the cancer.
What is the difference between mesothelioma cell types and tumor location?
Cell type refers to the type of cells that make up the tumors. Tumor location refers to where the cancer first began growing, such as the lining of the lungs or abdomen.
What’s the rarest type of mesothelioma?
Testicular and pericardial mesothelioma are the rarest forms, each accounting for less than 1% of cases.
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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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