Stage 4 Mesothelioma

Stage 4 is the most advanced stage of mesothelioma, and it's the most difficult stage to treat. There are several treatment options that can improve quality of life and help stage 4 mesothelioma patients feel more comfortable.


Written by Jenna Campagna, RN


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What Is Stage 4 Mesothelioma?

Stage 4 mesothelioma is characterized by distant metastasis, which means the cancer has spread to different areas of the body. Mesothelioma can be difficult to treat once it has reached this stage.

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Some basic characteristics of stage 4 mesothelioma are:

  • Aggressive tumor spread to nearby organs
  • Lymph nodes are affected, evident by them swelling
  • Cancer is present in other areas of the body, such as the neck, head or vertebrae
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Some basic characteristics of stage 4 mesothelioma are:

  • Aggressive tumor spread to nearby organs
  • Lymph nodes are affected, evident by them swelling
  • Cancer is present in other areas of the body, such as the neck, head or vertebrae

Stage 4 mesothelioma is usually not treatable with aggressive mesothelioma therapies. Fortunately, there are other options available to help patients feel more comfortable, reduce their symptoms and help extend their life.

What Symptoms to Expect With Stage 4 Mesothelioma

Stage 4 mesothelioma patients usually experience more severe symptoms than an individual diagnosed with a less-advanced cancer. Some mesothelioma symptoms don’t appear until stage 4, and the symptoms that were already present get worse and cause more discomfort.

If you are experiencing many of these symptoms, schedule a doctor’s appointment immediately. You should undergo scans and testing to determine if you have mesothelioma. This is how to receive a mesothelioma diagnosis. If so, you can receive important medical care that diminishes these symptoms and alleviates your discomfort.

Patients may experience:

  • Intense abdominal or chest pain
  • Consistent fluid buildup in the chest or stomach
  • 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 many of these symptoms, schedule a doctor’s appointment immediately. You should undergo scans and testing to determine if you have mesothelioma. This is how to receive a mesothelioma diagnosis. If so, you can receive important medical care that diminishes these symptoms and alleviates your discomfort.

Stage 4 Mesothelioma Treatment Options

Mesothelioma usually forms in either the pleura (the lining between your chest and lung cavity) or the peritoneum (the membrane covering your abdominal cavity). In stage 4, tumors have spread far beyond these areas. They sometimes reach the liver, heart or kidneys.

The extent of this stage makes aggressive mesothelioma treatment unlikely. In many circumstances, stage 4 mesothelioma cannot be treated with surgeries that remove the bulk of the tumors.

Depending on the individual case, though, some doctors may use invasive surgery for this stage. These surgeries include:

Stage 4 mesothelioma treatment often centers around pain-relief therapies. Chemotherapy, radiation and fluid-draining procedures are most often used for this stage of mesothelioma. The priority for physicians is to alleviate discomfort and to improve quality of life.

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. If this happens, then patients may be eligible for surgery to resect the tumors.

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Chemotherapy involves cancer-fighting drugs attacking mesothelioma cells, shrinking tumors and slowing the disease’s growth. The two chemotherapy drugs approved for mesothelioma are pemetrexed and cisplatin. Most doctors use these drugs in tandem to slow the disease as much as possible.

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Radiation involves high-energy beams targeted at the disease’s location. This therapy can shrink tumors and kill mesothelioma cells. It’s also a targeted therapy, which means it does not affect much of a patient’s healthy tissue.

Radiation is primarily used for pleural mesothelioma — but not for peritoneal mesothelioma. Radiation can extend a patient’s life and alleviate pain by reducing the size of tumors along the chest wall. This result can make breathing easier for the patient.

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Palliative Surgery

Palliative mesothelioma surgery can improve quality of life while reducing symptoms for stage 4 patients. These operations improve life expectancy as well due to lowering fluid buildup and removing tumors.

Pleurodesis is a common palliative surgery for pleural mesothelioma. The presence of tumors in the pleural space causes fluid buildup (a symptom called “pleural effusions”). This symptom prevents the lungs from expanding as needed, which makes breathing difficult. Pleurodesis addresses this mesothelioma symptom.

The procedure involves draining fluid from the cavity (if needed) and then sealing it shut by sticking the two walls together. Doctors often use a talc mixture to irritate the two pleural linings, which causes them to expand and stick. It also can involve removing the tumors in the pleura. A pleurodesis helps the lungs expand like normal, which makes breathing easier.

The other palliative mesothelioma surgeries involve using a needle to remove fluid from the cavity where the cancer formed. These include:

  • Thoracentesis (pleural mesothelioma)
  • Paracentesis (peritoneal mesothelioma)
  • Pericardiocentesis (pericardial mesothelioma)
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Clinical Trials

Experimental treatments, like immunotherapy, can have better effects for patients than standard treatments. Some clinical trials are explicitly for treating late-stage patients, such as those with stage 4 mesothelioma. If you have this advanced of a diagnosis, consider enrolling in a clinical trial.


Patients with stage 4 mesothelioma usually have a poorer mesothelioma prognosis than earlier-stage patients. According to a study published on UpToDate, the median life expectancy for this stage of mesothelioma is 11 months following diagnosis.

While an early diagnosis is rare, most patients thankfully learn of their mesothelioma prior to stage 4. According to a study published in the Journal of Thoracic Oncology, only around 20% of patients were diagnosed with stage 4 mesothelioma.

The same study involved researching the benefits of surgery for this stage of the cancer. According to the analysis:

  • Patients had a median mesothelioma survival rate between 11 and 15 months, depending on the surgery
  • Patients undergoing a P/D had the best survival, a median of 15 months
  • Around 20% of stage 4 mesothelioma patients survived for two years

It is important to remember that a patient’s cell type, overall health, age and gender play a role in their prognosis. For instance, epithelioid patients often have better survival rates than sarcomatoid patients.

It is vital that patients and their loved ones understand that no two mesothelioma cases are alike. Not all stage 4 mesothelioma patients will undergo the same treatment approach or receive the same prognosis.

Second Opinion

A second opinion is critical in determining a patient’s staging and available treatment options. Late-stage patients, such as those with stage 4 mesothelioma, are often ineligible for life-saving surgery. It is extremely important that all patients receive an accurate diagnosis.

Many patients seek a second opinion from a mesothelioma specialist, who may reveal that the patient’s original stage was diagnosed incorrectly. According to the Journal of Thoracic Oncology study, around 13.5% of patients who initially receive a stage 4 diagnosis are downstaged to a lower stage.

The best way to receive an accurate diagnosis is to get a second opinion from a mesothelioma specialist. Doctors who specialize in treating this cancer are much more experienced in diagnosing and staging.

One mesothelioma survivor, Alexis K., is an example of why you should get a second opinion. She was initially diagnosed with stage 4 peritoneal mesothelioma because of the metastasis to her diaphragm. Getting a second opinion revealed that her mesothelioma was stage 2.

She received cytoreduction with HIPEC and, as of 2020, has survived for more than 13 years since her diagnosis.

Stage 4 by Different Staging Systems

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TNM System

TNM, which stands for “Tumor, Node, Metastasis”, is the most commonly used staging system for pleural mesothelioma. This system measures the size of tumors, the amount of lymph node involvement and level of metastasis.

TNM classifies stage 4 mesothelioma as having large-sized tumors, severe lymph node involvement and significant metastasis. Lymph nodes are often very swollen in this stage, and tumors have reached distant organs like the liver.

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Butchart System

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

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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 classify stage 4 patients as surgical candidates.

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Peritoneal Cancer Index

The peritoneal cancer index (PCI) classifies the extent of peritoneal mesothelioma within the abdominal cavity. This area 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 region and 0 meaning that tumors aren’t present.

PCI scores between 31 and 39 are correlated to a stage 4 mesothelioma diagnosis. If a patient receives this high of a score, then their abdominal cavity is overrun with tumors. Undergoing successful surgery to remove most of the tumors will be a challenge, but it’s not out of the question.

Speak with a peritoneal mesothelioma specialist to determine if you’re a candidate for surgery. We can help you find one using our free Doctor Match program.

Common Questions About Stage 4 Mesothelioma

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.

What are the symptoms of stage 4 mesothelioma?

Stage 4 mesothelioma symptoms continue worsening, with many patients experiencing a high-grade fever, night sweats, difficulty swallowing, anemia, coughing up blood, and face or arm swelling. Some of the early-stage symptoms, like difficulty breathing and fluid buildup, continue and may get more severe.

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.

How often do people have stage 4 mesothelioma?

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?

Most curative surgeries are not options for stage 4 mesothelioma, which means patients receive pain-relief care and possibly chemotherapy. These treatment options can reduce discomfort and slow disease progression.

Last Edited: October 26, 2020.

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