STAGING MELANOMA
You can determine the TNM classification and Stage of your melanoma by visiting the following website.
Two systems are used in concert to determine the stage of melanoma. These were described and published by the American Joint Commission of Cancer (AJCC) and are used world-wide to classify the patient’s disease and determine prognosis. The latest version is that which was determined in 2002, based on outcomes in 17,600 patients.1 2 3
A new version of the staging system, based on outcomes in 60,000 patients has been announced and will be published jointly by the AJCC and the International Union Against Cancer (UICC) in 2009. The major change in the 2009 AJCC/UICC Melanoma Staging System is the inclusion of mitotic activity in the primary as important prognostic factor. Mitotic activity is histologically defined as mitoses/mm2. A mitotic rate equal of greater than 1/mm2 denotes a melanoma at higher risk for metastasis. A test version of a program to determine the 5- and 10- year survival for an individual patient is available on the following Website: www.melanomaprognosis.org.
For patients with localized melanoma (Stage I/II melanoma), the significant prognostic factors were found to be gender, age, lesion site, tumor thickness, and ulceration and these are included in the predictive model. For patients with regional metastasis (Stage III melanoma), the significant factors were the same, with the added factors of tumor burden and number of nodes involved with melanoma. The Website allows one to insert these significant prognostic factors for an individual patient and it will use these factors to report estimated 5- and 10- year survival rates and confidence intervals.
One part of the staging system involves the TNM Classification. This uses characteristics of the primary tumor (T), the status of the regional lymph nodes (N), and whether or not there are distant metastases and their character (M). Details of the TNM Classification are given on the following page. An example of this system is used is that if a patient had a melanoma between 1.01 to 2 mm in thickness without ulceration, had microscopic involvement in 1 lymph node, and no evidence of distant metastasis, the classification would be T2aN1aM0.
The TNM system is then used to determine the Stage of the melanoma. This is shown following the description of the TNM system in Melanoma Stage below. The Stage ranges from I to IV. Patients with Stage I disease have the best prognosis and those in successive stages have increasingly worse prognosis. Stage I and II represent the primary melanoma without regional or distant metastases. There are subdivisions within Stage I and II depending on the histopathology of the primary (tumor thickness, level, and whether or not ulceration was present. Stage III represents regional metastases and Stage IV represents distant metastases. There are also subdivisions within these Stages depending on the characteristics of the nodal involvement (Stage III) or location of metastases (Stage IV).
TNM Classification
Clin. |
Path. |
Primary Tumor (T) Date_______________________
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TX |
Primary Cannot Be Assessed (e.g., shave biopsy or regressed melanoma) |
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T0 |
No evidence of primary tumor |
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Tis |
Melanoma in situ |
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T1 |
Melanoma < 1.0 mm in thickness with or without ulceration |
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T1a |
Melanoma < 1.0 mm in thickness and level II or III, no ulceration |
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T1b |
Melanoma < 1.0 mm and level IV or V or with ulceration |
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T2 |
Melanoma 1.01 – 2.0 mm in thickness with or without ulceration |
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T2a |
Melanoma 1.01 – 2.0 mm in thickness, no ulceration |
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T2b |
Melanoma 1.01 – 2.0 mm in thickness, with ulceration |
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T3 |
Melanoma 2.01 – 4.0 mm in thickness with or without ulceration |
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T3a |
Melanoma 2.01 – 4.0 mm in thickness without ulceration |
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T3b |
Melanoma 2.01 – 4.0 mm in thickness with ulceration |
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T4 |
Melanoma > 4.0 mm in thickness with or without ulceration |
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T4a |
Melanoma > 4.0 mm in thickness without ulceration |
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T4b |
Melanoma > 4.0 mm in thickness with ulceration |
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Clin |
Path |
Regional Lymph Nodes (N) Date_______________________ |
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NX |
Regional nodes cannot be assessed |
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N0 |
No regional node metastasis |
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N1 |
Metastasis in one lymph node |
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N1a |
Clinically occult (microscopic) metastasis in one lymph node |
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N1b |
Clinically apparent (macroscopic) metastasis in one lymph node |
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N2 |
Metastasis in two to three regional nodes or intralymphatic regional metastasis without nodal metastases |
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N2a |
Clinically occult (microscopic) metastasis in two to three lymph nodes |
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N2b |
Clinically apparent (macroscopic) metastasis in two to three lymph nodes |
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N2c |
Satellite or in-transit metastasis without nodal metastasis |
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N3 |
Metastasis in four or more regional nodes or matted metastatic nodes, or in-transit metastasis or satellite(s) with metastasis in regional node(s) |
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Clin |
Path |
Distant Metastasis (M) Date_______________________ |
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MX |
Distant metastasis cannot be assessed |
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M0 |
No distant metastasis |
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M1 |
Distant metastasis |
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M1a |
Metastasis to skin, subcutaneous tissues or distant lymph nodes |
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M1b |
Metastasis to lung |
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M1c |
Metastasis to all other visceral sites or distant metastasis at any site associated with an elevated serum lactic dehydrogenase (LDH) |
Melanoma Stage*
Stage
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TNM |
Characteristics |
Stage I
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No nodal or distant metastases and |
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IA |
T1aN0M0 |
Primary tumor <1.0 mm in thickness without ulceration |
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IB |
T1bN0M0 |
Primary tumor < 1.0 mm in thickness with ulceration or level IV or V |
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T2aN0M0 |
Primary tumor 1.01 – 2.0 mm in thickness without ulceration |
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Stage II
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No nodal or distant metastases and |
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IIA |
T2bN0M0 |
Primary tumor 1.01 – 2.0 mm in thickness with ulceration |
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T3aN0M0 |
Primary tumor 2.01 – 4.0 mm in thickness without ulceration |
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IIB |
T3bN0M0 |
Primary tumor 2.01 – 4.0 mm in thickness with ulceration |
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T4aN0M0 |
Primary tumor > 4.0 mm in thickness without ulceration |
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IIC |
T4bN0M0 |
Primary tumor > 4.0 mm in thickness with ulceration |
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Stage III
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Regional metastasis |
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IIIA |
T1-4aN1aM0 |
1 node with micrometastasis ** and no ulceration of the primary tumor |
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T1-4aN2aM0 |
2-3 nodes with micrometastasis and no ulceration of the primary tumor |
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IIIB |
T1-4bN1aM0 |
1 node with micrometastasis and ulceration of the primary tumor |
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T1-4bN2aM0 |
2-3 nodes with micrometastasis and ulceration of the primary tumor |
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T1-4aN1bM0 |
1 node with macrometastasis and no ulceration of the primary tumor |
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T1-4aN2bM0 |
2-3 nodes with macrometastasis and no ulceration of the primary tumor |
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T1-4a/bN2cM0 |
In transit met(s)/satellite(s) without metastatic nodes with or without ulceration of the primary |
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IIIC |
T1-4bN1bM0 |
1 node with macrometastasis and ulceration of the primary tumor |
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T1-4bN2bM0 |
2-3 nodes with macrometastasis and ulceration of the primary tumor |
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Any TN3M0 |
4 or more nodes with micro- or macrometastasis or matted nodes or satellite or in-transit metastases with metastatic nodes with or without ulceration of the primary |
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Stage IV
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Distant metastasis |
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M1a |
AnyTAnyNM1a |
Skin, subcutaneous, and/or distant lymph node metastasis, normal LDH |
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M1b |
AnyTAnyNM1b |
Lung metastasis, normal LDH |
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M1c |
AnyTAnyNM1c |
Other visceral metastasis or any distant site of metastasis and elevated LDH |
* AJCC Cancer Staging Manuel, Sixth Edition, pg. 211-212, 2002
** Micrometasis: clinically occult disease (nodes not palpable); Macrometasis: clinically apparent disease (nodes palpable)
Bibliography
- AJCC Cancer Staging Manual (ed Sixth Edition). New York, Springer, 2002
- Balch CM, Buzaid AC, Soong SJ, et al: Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol 19:3635-48., 2001
- Balch CM, Soong SJ, Gershenwald JE, et al: Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol 19:3622-34., 2001
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