Skin-Melanocytic Tumors - Staging of melanomas

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Skin-Melanocytic Tumors

Last major update: November 2008 - next update November 2009

Revised: 11 July 2009

Author: Nat Pernick, M.D., PathologyOutlines.com, Inc.

Staging

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● Primary difference between clinical and pathologic stage grouping is whether regional lymph nodes are staged clinically (including radiologic exam) or pathologically (after excision)

● Clinical staging: perform after complete excision of tumor, microstaging (pathologic exam to determine Breslow thickness and Clark level of invasion) and assessment of metastases

● Note: significant survival differences are noted based on clinical versus pathologic staging

● Pathologic staging: uses clinical staging information plus pathologic examination of regional lymph nodes and pathologic confirmation of metastases

Primary tumor (T)

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● TX: primary tumor cannot be assessed (e.g. shave biopsy or regressed melanoma)

● T0: no evidence of primary tumor

● Tis: melanoma in situ

● T1: melanoma 1.0 mm or less in thickness with or without ulceration

● T1a: melanoma 1.0 mm or less in thickness and level II or III, no ulceration

● T1b: melanoma 1.0 mm or less in thickness and level IV or V or with ulceration

● T2: melanoma 1.01 - 2.0 mm in thickness with or without ulceration

● T2a: melanoma 1.01 - 2.0 mm in thickness, no ulceration

● T2b: melanoma 1.01 - 2.0 mm in thickness, with ulceration

● T3: melanoma 2.01 - 4.0 mm in thickness with or without ulceration

● T3a: melanoma 2.01 - 4.0 mm in thickness, no ulceration

● T3b: melanoma 2.01 - 4.0 mm in thickness, with ulceration

● T4: melanoma greater than 4.0 mm in thickness with or without ulceration

● T4a: melanoma greater than 4.0 mm in thickness, no ulceration

● T4b: melanoma greater than 4.0 mm in thickness, with ulceration

● Notes: ulceration means absence of intact epidermis overlying the primary melanoma, as assessed by histologic examination

Regional lymph nodes (N)

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● NX: regional lymph nodes cannot be assessed

● N0: no regional lymph node metastasis

● N1: metastasis in one lymph node

● N1a: clinically occult (microscopic) metastasis

● N1b: clinically apparent (macroscopic) metastasis

● N2: metastasis in 2-3 regional nodes or intralymphatic regional metastasis without nodal metastases

● N2a: clinically occult (microscopic) metastasis

● N2b: clinically apparent (macroscopic) metastasis

● N2c: satellite or in-transit metastasis without nodal metastasis

● 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)

● Satellite metastases: defined arbitrarily as intralymphatic metastases occurring within 2 cm of the primary melanoma

● In-transit metastases: defined arbitrarily as intralymphatic metastases occurring more than 2 cm from the primary melanoma but before the first echelon of regional lymph nodes

● Regional nodal metastases: disease confined to one nodal basin or two contiguous nodal basins

● Note: HMB45 or MelanA positive isolated cells in sentinel nodes appear to have no prognostic significance, at least short term (AJSP 2007;31:1175)

Distant Metastases (M)

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● MX: distant metastasis cannot be assessed

● M0: no distant metastasis

● M1: distant metastasis

● M1a: metastasis to skin, subcutaneous tissues or distant lymph nodes

● M1b: metastasis to lung

● M1c: metastasis to all other visceral sites or distant metastasis at any site associated with an elevated serum lactic dehydrogenase (LDH)

Clinical stage grouping

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● 0 : Tis N0 M0

● IA : T1a N0 M0 ()

● IB : T1b N0 M0 or T2a N0 M0

● IIA : T2b N0 M0 or T3a N0 M0

● IIB : T3b N0 M0 or T4a N0 M0

● IIC : T4b N0 M0

● III : Any T, N1-N3, M0

● IV : Any T, any N, M1

● Note: clinical staging includes microstaging of the primary melanoma and clinical/radiologic examination for metastases, but no pathologic examination of lymph nodes

● Stages I/II: no evidence of metastases; stage I are considered low risk for metastases / mortality, and stage II are considered intermediate risk

● Stage III: regional metastases to lymph nodes, satellite metastases or in-transit metastases; no substaging is done

● Stage IV: distant metastases

Pathologic stage grouping and 5 year survival

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● 0 : Tis N0 M0

● IA : T1a N0 M0 (95%)

● IB : T1b N0 M0 or T2a N0 M0 (89-91%)

● IIA : T2b N0 M0 or T3a N0 M0 (77-79%)

● IIB : T3b N0 M0 or T4a N0 M0 (63-67%)

● IIC : T4b N0 M0 (45%)

● IIIA : T1-T4a, N1a or N2a, M0 (67%)

● IIIB : T1-T4b, N1a or N2a, M0 or T1-T4a, N1b or N2b, M0 or T1-T4b, N2c, M0 (52-54%)

● IIIC : T1-T4b, N1b or N2b, M0 or any T, N3 M0 (24-28%)

● IV : Any T, any N, M1

● Stages I/II: no evidence of metastases (regional or distant); stage I are considered low risk for metastases / mortality, and stage II are considered intermediate risk

● Stage III: regional metastases to lymph nodes, satellite metastases or in-transit metastases; stage IIIA are considered to have intermediate risk for distant metastases / survival, stage IIIB to have high risk and stage IIIC to have very high risk

● Stage IV: distant metastases

Tables

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● TNM classification

Notes

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● Increased complexity of AJCC 2002 system did not improve its predictive ability over the simpler AJCC 1997 (Cancer 2006;106:163)

Additional references

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● CA Cancer J Clin 2004;54:131, Cancer Control 2002;9:9, Staging Tool

End of Skin-Melanocytic Tumors > Staging of melanomas

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