An Evidence-based Staging System for Cutaneous Melanoma1

Authors

  • Dr. Charles M. Balch MD,

    1. Balch is Executive Vice-President and CEO, American Society of Clinical Oncology, Alexandria, VA and Professor, Surgery and Oncology, Johns Hopkins Medical Center, Baltimore, MD
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  • Dr. Seng-Jaw Soong PhD,

    1. Soong is Professor, Departments of Medicine and Biostatistics, and Director, Biostatistics and Bioinformatics Unit, University of Alabama Comprehensive Cancer Center, Birmingham, AL
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  • Dr. Michael B. Atkins MD,

    1. Atkins is Director, Biologic Therapy and Cutaneous Oncology Programs; Associate Director, Clinical Research; and Professor, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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  • Dr. Antonio C. Buzaid MD,

    1. Buzaid is Executive Director, Oncology Center, Hospital Sirio Libanes, São Paulo, Brazil
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  • Dr. Natale Cascinelli MD,

    1. Cascinelli is Scientific Director, Italian National Cancer Institute, and President, WHO Melanoma Program, Milan, Italy
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  • Dr. Daniel G. Coit MD,

    1. Coit is Co-leader, MSKCC Melanoma Disease Management Team, Memorial Sloan-Kettering Cancer Center, New York, NY
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  • Dr. Irvin D. Fleming MD,

    1. Fleming is Professor, Department of Surgery, University of Tennessee for the Health Sciences, Memphis, TN
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  • Dr. Jeffrey E. Gershenwald MD,

    1. Gershenwald is Associate Professor, Departments of Surgery and Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX
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  • Dr. Alan Houghton Jr. MD,

    1. Houghton is Chief, Clinical Immunology Service; Head, Melanoma Disease Management Team; and Chairman, Immunology Program at Memorial Sloan-Kettering Cancer Center, New York, NY
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  • Dr. John M. Kirkwood MD,

    1. Kirkwood is Professor and Vice-Chairman, Clinical Research, Department of Medicine, and Director, Melanoma Center, University of Pittsburgh Medical Center, Pittsburgh, PA
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  • Dr. Kelly M. McMasters MD,

    1. McMasters is Professor and Director, Division of Surgical Oncology, University of Louisville Medical Center, Louisville, KY
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  • Dr. Martin F. Mihm MD,

    1. Mihm is Clinical Professor, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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  • Dr. Donald L. Morton MD,

    1. Morton is Medical Director and Surgeon-in-Chief, John Wayne Cancer Institute, Saint John's Health Center, Santa Monica, CA
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  • Dr. Douglas S. Reintgen MD,

    1. Reintgen is Director, Lakeland Regional Cancer Center, Lakeland, FL
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  • Dr. Merrick I. Ross MD,

    1. Ross is Professor, Department of Surgery, and Chief, Melanoma Section, Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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  • Dr. Arthur Sober MD,

    1. Sober is Professor, Department of Dermatology, Harvard Medical School, and Associate Chief, Department of Dermatology, Massachusetts General Hospital, Boston, MA
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  • Dr. John A. Thompson MD,

    1. JA Thompson is Associate Professor, Department of Medicine, University of Washington, and Co-director, Melanoma Clinic, University of Washington Medical Center, Seattle, WA
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  • Dr. John F. Thompson MD

    1. JF Thompson is Professor, Department of Surgery (Melanoma and Surgical Oncology), University of Sydney, and Executive Director, Sydney Melanoma Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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  • 1

    1 Three meetings held by the AJCC Melanoma Staging Committee were partially supported by an unrestricted educational grant from Schering Pharmaceutical, Kenilworth, NJ.

  • This article is available online at: http://CAonline.AmCancerSoc.org

Abstract

A completely revised staging system for cutaneous melanoma was implemented in 2003. The changes were validated with a prognostic factors analysis involving 17,600 melanoma patients from prospective databases. This major collaborative study of predicting melanoma outcome was conducted specifically for this project, and the results were used to finalize the criteria for this evidence-based staging system. In fact, this was the largest prognostic factors analysis of prospectively followed melanoma patients ever conducted. Important results that shaped the staging criteria involved both the tumor-node-metastasis (TNM) criteria and stage grouping for all four stages of melanoma. Major changes in the staging include: (1) melanoma thickness and ulceration are the dominant predictors of survival in patients with localized melanoma (Stages I and II); deeper level of invasion (ie, IV and V) was independently associated with reduced survival only in patients with thin or T1 melanomas. (2) The number of metastatic lymph nodes and the tumor burden were the most dominant predictors of survival in patients with Stage III melanoma; patients with metastatic nodes detected by palpation had a shorter survival compared with patients whose nodal metastases were first detected by sentinel node excision of clinically occult or “microscopic” metastases. (3) The site of distant metastases (nonvisceral versus lung versus all other visceral metastatic sites) and the presence of elevated serum lactate dehydrogenase (LDH) were the dominant predictors of outcome in patients with Stage IV or distant metastases. (4) An upstaging was implemented for all patients with Stage I, II, and III disease when a primary melanoma is ulcerated by histopathological criteria. (5) Satellite metastases around a primary melanoma and in-transit metastases were merged into a single staging entity that is grouped into Stage III disease. (6) A new convention was implemented for defining clinical and pathological staging so as to take into account the new staging information gained from lymphatic mapping and sentinel node biopsy.

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