Staging is the process of finding out how far the mesothelioma cancer has spread. Doctors determine which treatments to use based on the mesothelioma stage, or the severity of the disease. The major mesothelioma staging system used is a TNM system, similar to the system used for most other cancers. T stands for tumor (its size and how far it has spread to nearby organs), N stands for spread to lymph nodes, and M is for metastasis (whether it has spread to distant organs).

Mesothelioma stage grouping assigns a number to represent information about tumor, lymph nodes, and metastasis.

T Mesothelioma Stages

• T1: The cancer has only spread to the outer lining of either the right or the left lung.

• T2: The cancer has spread to the outer lining of the lung, to the diaphragm, and or into the lung itself on either the right or the left side.

• T3: The cancer has spread into the first layer of the chest wall, the fatty part of the mediastinum (heart, esophagus, trachea, and lymph nodes in the chest), a single place in the chest wall, or the outer covering of the heart.

• T4: The cancer has spread into the chest wall-either muscle or ribs, through the diaphragm, into any organ of the mediastinum, into the spine, into both sides of the chest, through the heart lining or into the heart, or into the nerves leading into the arm.

N Mesothelioma Stages

• N0: No spread to lymph nodes.

• N1: Spread to lymph nodes only on the same side of the chest as the mesothelioma.

• N2: Spread to lymph nodes where the windpipe branches into the bronchi, or to lymph nodes in the mediastinum on the same side of the chest as the mesothelioma.

• N3: Spread to lymph nodes on either side of the collarbone or to lymph nodes on the opposite side of the chest from the mesothelioma.

M Mesothelioma Stages

• M0: No spread to distant organs or areas.

• M1: The cancer has spread distantly.

After all TNM categories and numbers have been assigned, doctors can assign an overall mesothelioma stage of I, II, III, or IV. Patients with lower stage numbers have a better prognosis, or life expectancy.

How Was This Diagnosis Determined, and How Accurate Were the Tests?

Although you probably took many different tests leading up to your diagnosis, a tissue biopsy is normally the final determining factor. Following are some tests your doctor may recommend, and what may or may not be concluded from these tests.

• X-rays, CT scans, and MRIs - See the imaging section for more on these techniques. On conventional x-ray film, mesothelioma appears as a markedly thickened, nodular, irregular pleural-based mass which covers the pleural surface. The tumor often encompasses the involved lung, but is only rarely seen bilaterally. Chest wall, diaphragmatic, and mediastinal invasion may be seen in advanced cases. Moderate to large pleural effusion is often noted on the affected side. On CT scan, pleural thickening greater than 1 cm can be identified in over 90% of cases; thickening which extends into the interlobular fissure is seen in 85% of cases. Absence of pleural thickening does not preclude mesothelioma, and at times, the only CT finding is that of pleural effusion.
  
   

• Cytology - Testing of the pleural fluid for malignant cells is considered to have limited value in diagnosing mesothelioma. Negative or inconclusive readings account for nearly 85% of all fluid tested. Even with a positive fluid report, many doctors prefer to perform a confirming tissue biopsy as long as it does not compromise the patient's health.
  
   

• Needle Biopsy - In this test, done under local anesthetic, a large hollow needle is inserted through the skin and into the chest cavity. The needle is then rotated, and as it is taken out, tissue samples are collected. Because of the small sample size of the tissue, this type of biopsy is considered to be only 25-60% accurate in diagnosing mesothelioma. Because tumor seeding may occur along the needle tract in approximately 20% of patients, local radiation therapy may be used in conjunction with this test.
  
   

• Open biopsy - This type of biopsy is considered to be the most accurate for mesothelioma diagnosis, and is the procedure of choice because it affords the pathologist a larger tissue sample.. It is done in a hospital under general anesthetic. As with a needle biopsy, local radiation may be used because of the possibility of tumor seeding.

Can I Be Treated by the Doctor Who Diagnosed My Mesothelioma?

If the doctor who diagnosed your mesothelioma is your primary physician, he will most likely refer you to a local oncologist for treatment. The oncologist may offer what he or she feels are the best treatment options, or, if their knowledge of this disease is limited, may suggest you seek out a doctor who specializes in mesothelioma. Most often these physicians are located at larger, teaching hospitals such as those listed in the Comprehensive Cancer Center Section. These facilities are ranked as state-of-the-art cancer centers, and are highly respected for their patient care and innovative cancer treatments. If your choice of treatment involves a radical surgical procedure or a clinical trial involving new, as yet unproven drugs, these facilities may be best for you. If your treatment involves an already-approved, standard form of chemotherapy, this can be carried out locally.

What Treatment Options Will I Be Offered?

Treatment options may vary according to the age and over-all health of the patient, and the extent of the disease. It is important to be informed of all available options for your particular case, so that you can make decision on the option you feel most comfortable with. Surgery, chemotherapy, and clinical trials, as well as new approaches such as photodynamic therapy, immunotherapy, and gene therapy may be offered. Speak openly with your doctor regarding suggested procedures. Questions may include:

• Why is this procedure best for me?
• What does the procedure entail?
• What are the advantages/disadvantages of this treatment (i.e, will this procedure limit my eligibility for other treatments)?
• What are the possible risks or adverse side effects?
• What are the response, survival, and mortality rates associated with this procedure?

Is Palliative Treatment an Option?

In some circumstances, age, contributing health problems, or advanced disease may make aggressive treatment impossible. In these cases, palliative care (that which treats the symptoms, but not the disease itself) may be appropriate. If you opt for palliative care, it is doubly important to communicate fully with your doctor. Many symptoms of mesothelioma can be alleviated or substantially lessened if you are completely open with your doctor. Each time you have an appointment, tell your doctor how you feel, what discomfort you are experiencing, and your level of pain. A good doctor should be willing to address your questions and concerns.