BACKGROUND: Classification schemas for cancers are useful for predicting overall survival and selecting patients for treatment. Historically, the most important factors in determining prognosis in patients with melanoma have been tumor thickness and lymph node status. Sentinel lymph node mapping defines a subset of patients with microscopic metastatic disease can be identified, offering greater accuracy in staging. METHODS: The authors reviewed studies evaluating the prognostic factors that are significant in predicting survival in patients with melanoma. The newly revised American Joint Committee on Cancer (AJCC) staging system for melanoma is compared with the 1997 AJCC staging system currently in use. RESULTS: The changes in the new AJCC melanoma staging system reflect the new prognostic factors that have been found to be important in predicting survival. These include primary tumor thickness (tumor depth in millimeters is more predictive than the level of invasion) and ulceration, number of metastatic lymph nodes, micrometastatic disease based on the sentinel lymph node biopsy technique or elective node dissection, the site(s) of distant metastatic disease and serum LDH levels. CONCLUSIONS: Major revisions have been made to form a new AJCC staging system for melanoma, which will become official in 2002. This system will provide more accurate and precise information regarding patient prognosis. Validation studies are needed to confirm the accuracy of this revised staging system.

Biopsy, Needle↗

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Annals of surgical oncology impact factor/rating has dramatically increased.

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Bibliometrics↗

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An evidence-based staging system for cutaneous melanoma.

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.

Databases, Factual↗