Melanoma diagnostic study of choice
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.; Serge Korjian M.D.Sabawoon Mirwais, M.B.B.S, M.D.[2]
Overview
All patients with suspected melanoma require biopsy. Findings on biopsy may distinguish the sub-type and the stage of melanoma. Staging of melanoma is essential to determine the prognosis. Staging is based on the eight edition American Joint Committee on Cancer (AJCC) melanoma TNM Classification.
Diagnostic Study of Choice
The following algorithm illustrates the approach to patients with suspected melanoma.[1]
Suspicious pigmented lesion | |||||||||||||||||||||||||||||||||||||||||||||||
Biopsy | |||||||||||||||||||||||||||||||||||||||||||||||
Inadequate | |||||||||||||||||||||||||||||||||||||||||||||||
Rebiopsy | |||||||||||||||||||||||||||||||||||||||||||||||
Melanoma confirmed | |||||||||||||||||||||||||||||||||||||||||||||||
Breslow thickness | Ulceration status | Mitotic rate | Depth and peripheral margin status | Presence of satellitosis | Clark level for lesions ≤ 1 mm | ||||||||||||||||||||||||||||||||||||||||||
Reassessment with complete physical examination, including neurological exam and lymph node assessment | |||||||||||||||||||||||||||||||||||||||||||||||
Biopsy
- Patients who have lesions suspected to be melanoma should always be biopsied.[1]
- An excisional biopsy (either elliptical, punch, or saucerization) of the thickest portion of the lesion with 1-3 mm margins is recommended.[1]
- Shave biopsy is acceptable only when the index of suspicion for melanoma is low.[1]
- The following should be reported when a biopsy is being reported:[1]
- Location
- Regression
- Tumor infiltrating lymphocytes
- Breslow's depth and vertical growth phase
- Histologic ulceration
- Clark level
- Angiolymphatic invasion
- Neurotropism
- Histologic subtype
To view the histopathologic characteristic features of all subtypes of melanoma, click here.
Staging
Eight Edition American Joint Committee on Cancer (AJCC) Melanoma TNM Staging System
Primary Tumor (T) Classification[2][3][4][5]
| T classification | Thickness | Ulceration status |
|---|---|---|
| TX: Primary tumor thickness cannot be assessed (eg, diagnosis by curettage) | Not applicable | Not applicable |
| T0: No evidence of primary tumor (eg, unknown primary or completely regressed melanoma) | Not applicable | Not applicable |
| Tis (Melanoma in situ) | Not applicable | Not applicable |
| T1 | ≤ 1.0 mm | or unspecified |
| T1a | < 0.8 mm | No ulceration |
| T1b | < 0.8 mm | Ulceration present |
| 0.8 – 1.0 mm | With or without ulceration | |
| T2 | > 1.0 – 2.0 mm | Unknown or unspecified |
| T2a | > 1.0 – 2.0 mm | No ulceration |
| T2b | > 1.0 – 2.0 mm | Ulceration present |
| T3 | > 2.0 – 4.0 mm | Unknown or unspecified |
| T3a | > 2.0–4.0 mm | No ulceration |
| T3b | > 2.0–4.0 mm | Ulceration present |
| T4 | > 4.0 mm | Unknown or unspecified |
| T4a | > 4.0 mm | No ulceration |
| T4b | > 4.0 mm | Ulceration present |
Regional Lymph Nodes (N) Classification[6]
| N Classification | Number of Nodes | Presence of In-Transit, Satelite, and/or microsatellite Metastases |
|---|---|---|
| NX | Regional nodes not assessed (eg, sentinel lymph node [SLN] biopsy not performed, regional nodes previously removed for another reason); Exception: pathological N category is not required for T1 melanomas, use clinical N information | No |
| N0 | No regional metastases detected | No |
| N1 | One tumor-involved node or any number of in-transit, satellite, and/or microsatellite metastases with no tumor-involved nodes | |
| N1a | One clinically occult (i.e., detected by SLN biopsy) | No |
| N1b | One clinically detected | No |
| N1c | No regional lymph node disease | Yes |
| N2 | Two or 3 tumor-involved nodes or any number of in-transit, satellite, and/or micro- satellite metastases with one tumor-involved node | |
| N2a | 2 or 3 clinically occult (i.e., detected by SLN biopsy) | No |
| N2b | 2 or 3 nodes, at least one of which was clinically detected | No |
| N2c | One clinically occult or clinically detected | Yes |
| N3 | 4 or more tumor-involved nodes or any number of in-transit, satellite, and/or microsatellite metastases with 2 or more tumor-involved nodes, or any number of matted nodes without or with in-transit, satellite, and/or microsatellite metastases | |
| N3a | 4 or more clinically occult (i.e., detected by SLN biopsy) | No |
| N3b | 4 or more, at least one of which was clinically detected, or the presence of any number of matted nodes | No |
| N3c | 2 or more clinically occult or clinically detected and/or presence of any number of matted nodes | Yes |
Distant Metastasis (M)[7]
| M Classification | Site | Serum LDH |
|---|---|---|
| M0 | No evidence of distant metastasis | Not applicable |
| M1 | Evidence of distant metastasis | |
| M1a | Distant metastasis to skin, soft tissue including muscle, and/or non-regional lymph node | Not recorded or unspecified |
| M1a (0) | Not elevated | |
| M1a (1) | Elevated | |
| M1b | Distant metastasis to lung with or without M1a sites of disease | Not recorded or unspecified |
| M1b (0) | Not elevated | |
| M1b (1) | Elevated | |
| M1c | Distant metastasis to non-CNS visceral sites with or without M1a or M1b sites of disease | Not recorded or unspecified |
| M1c (0) | Not elevated | |
| M1c (1) | Elevated | |
| M1d | Distant metastasis to CNS with or without M1a, M1b, or M1c sites of disease | Not recorded or unspecified |
| M1d (0) | Not elevated | |
| M1d (1) | Elevated |
Clark Level[8]
| Clark Level | Definition |
|---|---|
| Level I | Above the basement membrane |
| Level II | Infiltrating the papillary dermis |
| Level III | Between papillary dermis and reticular dermis |
| Level IV | Infiltrating the reticular dermis |
| Level V | Infiltrating subcutaneous tissue |
Staging of Melanoma
Stage 0: Melanoma in Situ, 100% Survival
- Tis (Clark Level I)
Stage I: Invasive Melanoma, 85-95% Survival
- T1a (Clark Level II-III)
- T1b (Clark Level IV-V)
- T2a
Stage II: High Risk Melanoma, 40-85% Survival
- T2b
- T3a
- T3b
- T4a
- T4b
Stage III: Regional Metastasis, 25-60% Survival
- N1
- N2
- N3
Stage IV: Distant Metastasis, 9-15% Survival
- M1a
- M1b
- M1c
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Coit DG, Andtbacka R, Anker CJ, Bichakjian CK, Carson WE, Daud A; et al. (2013). "Melanoma, version 2.2013: featured updates to the NCCN guidelines". J Natl Compr Canc Netw. 11 (4): 395–407. PMID 23584343.
- ↑ Scolyer RA, Judge MJ, Evans A, Frishberg DP, Prieto VG, Thompson JF, Trotter MJ, Walsh MY, Walsh NM, Ellis DW (December 2013). "Data set for pathology reporting of cutaneous invasive melanoma: recommendations from the international collaboration on cancer reporting (ICCR)". Am. J. Surg. Pathol. 37 (12): 1797–814. doi:10.1097/PAS.0b013e31829d7f35. PMC 3864181. PMID 24061524.
- ↑ Ge L, Vilain RE, Lo S, Aivazian K, Scolyer RA, Thompson JF (August 2016). "Breslow Thickness Measurements of Melanomas Around American Joint Committee on Cancer Staging Cut-Off Points: Imprecision and Terminal Digit Bias Have Important Implications for Staging and Patient Management". Ann. Surg. Oncol. 23 (8): 2658–63. doi:10.1245/s10434-016-5196-1. PMID 27075324.
- ↑ Patrick RJ, Corey S, Glass LF (November 2007). "The use of sequential serial sectioning of thin melanomas in determining maximum Breslow depth". J. Am. Acad. Dermatol. 57 (5 Suppl): S127–8. doi:10.1016/j.jaad.2006.02.007. PMID 17938027.
- ↑ Amin, Mahul (2017). AJCC cancer staging manual. Switzerland: Springer. ISBN 9783319406176.
- ↑ Amin, Mahul (2017). AJCC cancer staging manual. Switzerland: Springer. ISBN 9783319406176.
- ↑ Amin, Mahul (2017). AJCC cancer staging manual. Switzerland: Springer. ISBN 9783319406176.
- ↑ Clark WH, Elder DE, Guerry D, Braitman LE, Trock BJ, Schultz D; et al. (1989). "Model predicting survival in stage I melanoma based on tumor progression". J Natl Cancer Inst. 81 (24): 1893–904. PMID 2593166.