Stage 4 Mesothelioma

What Is Stage 4 Mesothelioma?

Stage 4 mesothelioma is the final and most advanced stage of this rare and aggressive cancer. Mesothelioma has four stages, beginning with stage 1. Stage 4 means the disease has spread to different areas of the body.

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 as much as possible.

What Mesothelioma Symptoms to Expect in Stage 4

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

Stage 4 mesothelioma treatment options include chemotherapy, immunotherapy, radiation therapy and palliative therapy. Doctors use these therapies to relieve pain and reduce symptoms.

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 mesothelioma surgery unlikely.

Some doctors may use surgery for specific cases of stage 4 mesothelioma. The options for mesothelioma surgery 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 tumor growth and extend life.

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

Immunotherapy for mesothelioma activates the immune system to attack cancer cells. The FDA has approved three immunotherapies for mesothelioma: Opdivo; Yervoy; and Keytruda. Opdivo and Yervoy are approved as a combination for people with pleural mesothelioma who cannot have surgery. Keytruda is also approved for people with pleural mesothelioma who cannot have surgery.

Radiation for mesothelioma 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 mesothelioma surgery can improve quality of life for patients while reducing symptoms. These operations extend survival by a few months as well. Palliative surgery options for mesothelioma are: pleurodesis; thoracentesis; and paracentesis.

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. Pleurodesis can also involve removing tumors in the pleura and helping the lungs expand like normal.

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)

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.

Prognosis

The mesothelioma prognosis for stage 4 is less than one year. According to a study published on UpToDate, the median life expectancy for stage 4 mesothelioma 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.

Remember that a patient’s cell type, overall health, age and gender play a role in prognosis.

Second Opinion

Receiving a second opinion is critical for people 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 the Journal of Thoracic Oncology study, around 13.5% of patients who initially receive a stage 4 diagnosis are down-staged.

Mesothelioma Survivors and Stage 4

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

Alexis 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.

How Each Mesothelioma Staging System Defines Stage 4

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 defines 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.

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.

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.

The peritoneal cancer index (PCI) is a staging system for peritoneal mesothelioma. It classifies how much tumors have spread 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 correlate to stage 4 mesothelioma.