Written By: Devin Golden

Stage 4 Mesothelioma

Stage 4 is the most advanced stage of mesothelioma. This means it’s the most difficult stage to treat. There are several options to improve quality of life and comfort for patients.

Karen Ritter, RN BSN

Medically Reviewed By

Karen Ritter, RN BSN

Registered Nurse

Karen Ritter, RN BSN

Medically Reviewed By

Karen Ritter, RN BSN

Registered Nurse


jump to icon


Important Facts About Stage 4 Mesothelioma

  • Stage 4 mesothelioma is the final stage, often called the “end stage” of mesothelioma.
  • Tumors may reach the brain, liver or other organs or body areas far away from the original tumor.
  • Most patients receive palliative treatment, which includes pain-relief therapy and medication.
  • The average survival is around one year, sometimes less, although immunotherapy is helping.

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 is very difficult to treat once it has reached this stage.

Stage 4 Mesothelioma Symptoms

Some characteristics of stage 4 mesothelioma are:

  • Aggressive tumor spread to organs
  • Lymph nodes affected, evident by their swelling
  • Cancer present in other areas of the body, such as the neck, head or vertebrae
Stage 4 Mesothelioma Symptoms

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 curative surgery. Fortunately, there are options to help patients feel comfortable, reduce their symptoms and extend their life.

What Symptoms to Expect With Stage 4 Mesothelioma

Stage 4 patients usually experience more severe symptoms than in earlier stages. Some mesothelioma symptoms don’t appear until stage 4, and the symptoms that were already present worsen.

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 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.

Stage 4 Mesothelioma Treatment Options

Mesothelioma starts in either the:

  • Pleura (the lining between your chest and lung cavity)
  • Peritoneum (the membrane covering your abdominal cavity)

In stage 4, tumors have spread far beyond these areas. They can reach the liver, heart or kidneys.

The spread of tumors makes aggressive mesothelioma treatment unlikely. Surgery to remove the bulk of tumors is too risky or unhelpful.

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

Stage 4 mesothelioma treatment 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. Immunotherapy, for instance, can slow tumor growth and extend life.

Chemotherapy Icon


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.

Radiation Icon


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 healthy tissue.

Radiation is primarily used for pleural mesothelioma but not 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.

Palliative Surgery Icon

Palliative Surgery

Palliative mesothelioma surgery can improve quality of life while reducing symptoms. These operations improve life expectancy as well.

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.

Pleurodesis drains fluid from the cavity (if needed) and seals it shut by sticking the two tissue linings together. Doctors may use a talc mixture to irritate the two pleural linings, which causes them to swell and stick together.

Pleurodesis can remove tumors in the pleura and help the lungs expand like normal.

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

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

Clinical Trials

Experimental treatments, like immunotherapy, can have better effects for patients than standard treatments. Immunotherapy enhances the immune system’s ability to fight mesothelioma. The FDA approved Opdivo and Yervoy together for unresectable cases (surgery isn’t possible), which is relevant for people with stage 4 mesothelioma.

Some clinical trials are explicitly for treating late-stage patients, such as those with stage 4 mesothelioma. If you are in this stage, consider enrolling in a clinical trial.


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

Most patients 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 reported 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 than sarcomatoid patients.

Second Opinion

A second opinion is critical in determining a patient’s staging and 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. These doctors may reveal 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.

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 she was in stage 2. As of 2021, she has survived for more than 13 years.

Stage 4 by Different Staging Systems

TNM System Icon

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, and tumors have reached distant organs like the liver.

Butchart System Icon

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 via the bloodstream to distant organs, such as the liver or brain.

Brigham System Icon

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 Icon

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.

Frequently Asked Questions About Stage 4 Mesothelioma

blue box icon

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.

blue box icon

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.

blue box icon

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.

blue box icon

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.

blue box icon

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.

Sources & Author

  1. Malignant Mesothelioma Treatment (Adult). Vanderbilt-Ingram Cancer Center. Retrieved from: https://www.vicc.org/cancer-info/adult-malignant-mesothelioma. Accessed: 11/15/22.
  2. Mesothelioma. National Organization for Rare Disorders. Retrieved from: https://rarediseases.org/rare-diseases/mesothelioma/. Accessed: 04/09/2020.
  3. 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.
  4. Mesothelioma: Symptoms and Signs. American Society of Clinical Oncology. Retrieved from: https://www.cancer.net/cancer-types/mesothelioma/symptoms-and-signs. Accessed: 04/10/19.
  5. 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.
  6. 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.
  7. Presentation, initial evaluation, and prognosis of malignant pleural mesothelioma. UpToDate. Retrieved from: https://www.uptodate.com/contents/presentation-initial-evaluation-and-prognosis-of-malignant-pleural-mesothelioma?topicRef=4625&source=see_link. Accessed: 04/14/2020.
  8. Life Expectancy in Pleural and Peritoneal Mesothelioma. Lung Cancer International. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5292397/. Accessed: 04/09/2020.
  9. Initial Analysis of the International Association For the Study of Lung Cancer Mesothelioma Database. Journal of Thoracic Oncology. Retrieved from: https://www.jto.org/article/S1556-0864(15)33132-4/fulltext. Accessed: 04/14/2020.
  10. A novel tumor‐node‐metastasis (TNM) staging system of diffuse malignant peritoneal mesothelioma using outcome analysis of a multi‐institutional database. American Cancer Society Journals. Retrieved from: https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.25640. Accessed: 04/14/2020.
  11. Peritoneal Cancer Index. ResearchGate. Retrieved from: https://www.researchgate.net/figure/Peritoneal-Cancer-Index-PCI-scoring-system-PCI-is-a-diagnostic-and-prognostic-tool_fig1_315691686. Accessed: 04/12/19.
Devin Golden

About the Writer, Devin Golden

Devin Golden is a 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.