What happens in stage 4 mesothelioma?

Stage 4 mesothelioma is the most advanced form of this cancer. It’s characterized by tumors reaching distant lymph nodes, spreading beyond the lung or abdominal cavities, and reaching the neck, spine or other areas. In peritoneal mesothelioma, the abdominal cavity is overrun with tumors.

How long can you live with stage 4 mesothelioma?

Stage 4 mesothelioma has an average life expectancy of 8-11 months. Each case is different and may present a better prognosis than the average. For instance, your cell type may affect your life expectancy. The same is true for your age, gender and overall health.

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Written By: Devin Golden

Stage 4 Mesothelioma

Stage 4 mesothelioma is the most advanced and final stage of mesothelioma. While treatment options are available, the prognosis is generally poor. Patients often receive treatment aimed at managing symptoms and improving quality of life. A second opinion from a specialist may reveal a lower stage and more promising prognosis.

Medically reviewed for accuracy by

Dr. Stephen Williams

Precision Oncology Scientist

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Important Facts About Stage 4 Mesothelioma

Stage 4 mesothelioma is the most advanced and final stage of the cancer and is sometimes referred to as the “end stage” of mesothelioma.
Tumors have typically spread (metastasized) to distant organs such as the brain, liver or other areas distant from where the cancer first appeared.
Treatments may focus more on managing symptoms and quality of life than on survival.
The average survival time is approximately one year, although immunotherapy and other advancements are giving hope for a longer life expectancy.

What Is Stage 4 Mesothelioma?

Stage 4 mesothelioma is the most advanced and final stage of the rare and aggressive cancer known as mesothelioma. This cancer forms in the lining of the lungs or abdominal cavity, and by stage 4 has spread significantly through the body.

Progression of Stage 4 Mesothelioma

Diagram illustrating stage 4 pleural mesothelioma, highlighting the pleura between the lung and chest wall.

Diagram illustrating Stage 4 peritoneal mesothelioma affecting the peritoneum and a small part of the abdomen

Pleura (the lining of the chest cavity) for pleural mesothelioma

Peritoneum (the membrane covering the abdominal cavity) for peritoneal mesothelioma

Some characteristics of stage 4 mesothelioma are:

Widespread tumor growth affecting multiple organs
Cancer cells spreading to lymph nodes
Metastasis to distant areas such as the neck, head or vertebrae

In stage 4, surgery is generally not an option. However, treatment is available to manage symptoms, improve comfort, and potentially extend survival.

Diagnosing Stage 4 Mesothelioma

Diagnosing stage 4 mesothelioma is common as most people do not realize they have the cancer until it has spread significantly. Research in the Journal of Thoracic Oncology found that approximately 20% of mesothelioma patients are diagnosed in stage 4.

Diagnostic Imaging

Mesothelioma imaging tests show the location and size of tumors in the patient’s body. This is crucial to diagnosing the stage.

Imaging tests for mesothelioma include:

X-rays

Chest X-rays are often the first imaging tool used to detect abnormalities, such as fluid buildup in the pleural space (pleural effusion), which may indicate mesothelioma.

CT scans

Computed Tomography (CT) scans provide more detailed images and can help identify the size, location, and extent of the tumor within the pleura or peritoneum. CT scans are instrumental in detecting early-stage tumors that might not be visible on routine X-rays.

MRI scans

Magnetic Resonance Imaging (MRI) scans may be employed for more detailed soft tissue evaluation, helping to assess the invasion of tumors.

Biopsy and Histological Analysis

A biopsy is the definitive method for diagnosing mesothelioma. Doctors collect a sample of tissue and send it to a lab to be examined under a microscope.

The biopsy types for mesothelioma are:

Thoracoscopy – A minimally invasive procedure where a camera is inserted into the chest cavity to visually inspect the pleura and obtain tissue samples for biopsy
Laparoscopy – Similar to thoracoscopy but used to obtain samples from the peritoneal cavity in patients with peritoneal mesothelioma
Needle biopsy – A needle is used to obtain tissue from the tumor for examination. This method may be used when the tumor is accessible or when a thoracoscopy or laparoscopy is not feasible.

What Mesothelioma Symptoms to Expect in Stage 4

Visual representation of the human body and its organs, focusing on common symptoms of mesothelioma.

General Symptoms of Mesothelioma

Signs and Symptoms of Stage 4 Mesothelioma

Intense abdominal or chest pain

Consistent fluid buildup in the chest or abdomen

Chronic fatigue, night sweats and fever

Coughing up blood (hemoptysis)

Difficulty swallowing (dysphagia)

Persistent cough

Hoarseness

Face or arm swelling

Loss of appetite

Shortness of breath (dyspnea)

If you are experiencing these symptoms, see your doctor right away. You should be evaluated for the cause of your symptoms. This is how to receive a mesothelioma diagnosis.

Stage 4 Mesothelioma Treatment Options

Stage 4 mesothelioma treatment options include chemotherapy, immunotherapy, radiation therapy and palliative therapy. These treatment options are primarily used to manage symptoms, alleviate pain, and improve the patient’s quality of life.

Surgery

In stage 4, tumors have possibly reached the liver, heart or kidneys. The spread of tumors to these vital organs – and the overall mass of the cancer in the body – makes mesothelioma surgery unlikely.

POTENTIAL SURGERY OPTIONS FOR STAGE 4 PATIENTS

Some doctors may use surgery for selective cases of stage 4 mesothelioma. The surgery options for mesothelioma are:

Pleurectomy with decortication (P/D) and extrapleural pneumonectomy (EPP) for pleural mesothelioma
Cytoreduction with heated intraperitoneal chemotherapy (HIPEC) for peritoneal mesothelioma

There is still long-term survival hope for patients. Chemotherapy, radiation and some emerging therapies could shrink the disease enough to “downstage” the patient to stage 3 or stage 2. Immunotherapy, for instance, can slow or even stop tumor growth and extend life.

Chemotherapy

Chemotherapy for mesothelioma uses cancer-fighting drugs to target mesothelioma cells, shrink tumors, and slow cancer progression. The U.S. Food and Drug Administration (FDA) has approved pemetrexed and cisplatin as chemotherapy for mesothelioma. Doctors typically use these drugs together to maximize their effectiveness in controlling the disease.

Immunotherapy

Immunotherapy for mesothelioma enhances the immune system’s ability to recognize and attack cancer cells. The FDA has approved three immunotherapy drugs to treat mesothelioma.

Opdivo (nivolumab) and Yervoy (ipilimumab) – Approved as a combination treatment for patients with pleural mesothelioma who cannot have surgery
Keytruda (pembrolizumab) – Approved for patients with pleural mesothelioma who cannot have surgery

These treatments help slow disease progression and may improve survival outcomes in some patients. Since they are approved for people who cannot have surgery, they are top options to consider for patients with stage 4 mesothelioma.

Radiation

Radiation for mesothelioma uses high-energy beams to target and destroy cancer cells while minimizing damage to healthy tissue. It can shrink tumors, slow disease progression, and alleviate symptoms.

Radiation is primarily used for pleural mesothelioma. Most doctors do not recommend radiation for peritoneal mesothelioma due to the potential damage to vital abdominal organs.
This therapy can help extend survival and relieve pain by reducing tumor size in the chest, making breathing easier.

Palliative Surgery

Palliative mesothelioma surgery aims to relieve symptoms and improve quality of life. While not curative, these procedures can extend survival by a few months and help manage complications.

Common Palliative Surgeries for Mesothelioma

Pleurodesis – This procedure for pleural mesothelioma removes excess fluid from the pleural space (pleural effusion) and seals the cavity to prevent further buildup.
Thoracentesis – This procedure for pleural mesothelioma uses a needle to drain excess fluid from the pleural cavity.
Paracentesis – This procedure for peritoneal mesothelioma uses a needle to drain excess fluid from the abdominal cavity.
Pericardiocentesis – This procedure for pericardial mesothelioma uses a needle to drain excess fluid from the sac surrounding the heart (pericardium).

These procedures help reduce discomfort and improve lung or organ function, enhancing the patient’s  overall well-being.

Clinical Trials

Clinical trials offer access to experimental treatments that may be more effective than standard therapies. Immunotherapy, for example, has shown promise in enhancing the immune system’s ability to combat mesothelioma.

Some clinical trials target late-stage cancer, including stage 4 mesothelioma. Patients often enroll in clinical trials to access emerging treatments that could improve their life expectancy.

Stage 4 Mesothelioma Life Expectancy

The prognosis for mesothelioma for stage 4 is typically less than one year. A study published in UpToDate reported a median life expectancy of 11 months following diagnosis.

Several factors influence an individual’s prognosis, including cell type, overall health, age, and gender. While stage 4 mesothelioma has a poor prognosis, some patients respond well to treatment and may live longer than expected.

Getting a Second Opinion

Receiving a second opinion is critical for patients diagnosed with stage 4 mesothelioma. A second opinion from a mesothelioma specialist could reveal a different stage, more treatment options, and a better prognosis.

According to a study published in the Journal of Thoracic Oncology, around 13.5% of patients who initially receive a stage 4 diagnosis were reclassified to a lower stage. People in lower stages are more likely to be considered for surgery and clinical trials. This reassessment can positively impact treatment decisions and potential outcomes.

Mesothelioma Survivors and Stage 4

There have been a few mesothelioma survivors who were diagnosed with stage 4 cancer. One mesothelioma survivor, Alexis Kidd, is an example of why you should get a second opinion.

Alexis Kidd

Peritoneal Mesothelioma Survivor

ALEXIS KIDD AND HER DIAGNOSIS

Alexis was diagnosed with peritoneal mesothelioma in stage 4. However, a second opinion revealed her cancer was in stage 2. With appropriate treatment, including surgery and chemotherapy, she has survived for more than 17 years as of 2025.

Her story underscores the potential benefits of getting a second opinion from a specialist and receiving treatment from experienced mesothelioma doctors.

How Each Mesothelioma Staging System Defines Stage 4

TNM System

The TNM system (Tumor, Node, Metastasis) is the most widely used staging system for pleural mesothelioma. It evaluates three key factors:

Tumor (T): Size and extent of the primary tumor
Node (N): Degree of lymph node involvement
Metastasis (M): Spread to distant organs

Example of the TNM System

Illustrated depiction of a tumor, showing the TNM system used for cancer staging and assessment.

Diagram illustrating the TNM system for classifying cancer metastasis and the growth of cancer cells.

In stage 4 mesothelioma, the TNM system defines the disease as having large tumors, extensive lymph node involvement and widespread metastasis. Lymph nodes are often significantly swollen and cancer has likely spread to distant organs such as the liver, brain or other areas of the body.

Butchart System

The Butchart System is the oldest staging system for pleural mesothelioma. It focuses on the size of tumors and where they’ve spread. In stage 4, the mesothelioma cells have spread through the bloodstream to distant organs, such as the liver or brain.

Brigham System

The Brigham System focuses on whether surgery is an option. It was designed by esteemed mesothelioma specialist Dr. David Sugarbaker when he worked at Brigham and Women’s Hospital in Boston. Since stage 4 mesothelioma has spread to distant organs and lymph nodes, this system does not consider stage 4 mesothelioma to be operable.

Peritoneal Cancer Index

The peritoneal cancer index (PCI) is a staging system for peritoneal mesothelioma. It classifies how much tumors have spread within the abdominal cavity.

The abdomen is split into 13 regions, and each region receives a score between 0 and 3. The score is based on the extent of tumors in the region, with 3 signaling that tumors cover the majority of the region and 0 meaning that tumors aren’t present.

PCI scores between 31 and 39 correlate to stage 4 mesothelioma.

Example of the PCI System

Diagram illustrating the stages of the digestive system, highlighting the 13 abdominal regions and their Peritoneal Cancer Index scores.

PCI Score: 8 - Stage 1

Frequently Asked Questions About Stage 4 Mesothelioma

What defines stage 4 mesothelioma?

Stage 4 mesothelioma is the most advanced of the four mesothelioma stages and usually means tumors have spread to distant lymph nodes, the neck, the spine or other areas. The prognosis for stage 4 mesothelioma is poor and treatment is limited.

What are the symptoms of stage 4 mesothelioma?

The symptoms of stage 4 mesothelioma include high-grade fever, night sweats, difficulty swallowing, anemia, coughing up blood, and face or arm swelling.

How long do people live with stage 4 mesothelioma?

People with stage 4 mesothelioma can live many years depending on factors such as their overall health, treatment, and their cell type. Typically, stage 4 mesothelioma has an average life expectancy of 8-11 months. Each case is different and may present a better prognosis than the average.

How often are people diagnosed with stage 4 mesothelioma?

People are diagnosed with stage 4 mesothelioma less than 15% of the time. In one study, around 13% of mesothelioma cases were diagnosed in stage 4. Fortunately, around 12% of the stage 4 cases were misdiagnosed by stage, later changing to a lower stage with a better prognosis.

What are the treatment options for stage 4 mesothelioma?

The treatment options for stage 4 mesothelioma include chemotherapy, immunotherapy and radiation therapy. Most curative surgeries are not options for stage 4 mesothelioma. Other options for mesothelioma treatment are available in clinical trials.

Sources & Author

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Signs and Symptoms of Mesothelioma. American Cancer Society. Retrieved from: https://www.cancer.org/cancer/malignant-mesothelioma/detection-diagnosis-staging/signs-symptoms.html. Accessed: 04/10/19.
Mesothelioma: Symptoms and Signs. American Society of Clinical Oncology. Retrieved from: https://www.cancer.org/cancer/types/malignant-mesothelioma/detection-diagnosis-staging/signs-symptoms.html. Accessed: 04/10/19.
Types of surgery for pleural mesothelioma. American Cancer Society. Retrieved from: https://www.cancer.org/cancer/malignant-mesothelioma/treating/surgery.html. Accessed: 04/23/2020.
Palliative Procedures for Malignant Mesothelioma. American Cancer Society. Retrieved from: https://www.cancer.org/cancer/malignant-mesothelioma/treating/palliative-procedures.html. Accessed: 05/01/2020.
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About the Writer, Devin Golden

Devin Golden is the senior content writer for Mesothelioma Guide. He produces mesothelioma-related content on various mediums, including the Mesothelioma Guide website and social media channels. Devin's objective is to translate complex information regarding mesothelioma into informative, easily absorbable content to help patients and their loved ones.