Staging Melanoma

STAGING MELANOMA

When all surgical and any imaging tests have been completed and pathology reports have been received the doctors will try to figure out if the cancer has spread, and if so, how far. This process is called staging. It helps determine how serious the cancer is and how best to treat it. Doctors also use a cancer’s stage when talking about prognosis and survival statistics. A preliminary clinical stage is assigned after the physical examination and initial biopsy. The final pathology report determines the pathologic stage and helps to determine the treatment options.

Melanoma stages are based on several factors. The staging system used for melanoma is the American Joint Committee on Cancer (AJCC) TNM system, which is based on 3 key pieces of information

T (thickness of the tumour)
N (lymph node involvement)
M (metastasis)

Each letter is then assigned a numerical value which has more details about the cancer associated with it. The results of this analysis are grouped into five stages (0, I, II, III, and IV).

(T) Thickness of the Tumour

(T): The the thickness of the tumour. How deep has the cancer grown into the skin? The thickness of the melanoma is called the Breslow measurement. In general, melanomas less than 1 millimeter (mm) thick (about 1/25 of an inch) have a very small chance of spreading. As the melanoma becomes thicker, it has a greater chance of spreading. Is the cancer ulcerated? Ulceration is a breakdown of the skin over the melanoma. The ulceration status tells us whether or not the tumour’s top skin is present or broken or missing (ulcerated).
Melanomas that are ulcerated tend to have a worse outlook. The T category is further divided into levels 1 to 4, base on how deep the tumour has grown into the skin, measured in millimetres (mm).

(N) The Spread to the Lymph Nodes

Has the cancer spread to nearby lymph nodes?

(M) The Spread (Metastasis) to the Distant Sites

Has the cancer spread to distant lymph nodes or distant organs such as the lungs or brain?

PATHOLOGIC STAGES

STAGES 0-IV

The staging system outlined below uses the pathologic stage. We have provided a simplified version of the latest TNM system as of January 2018. It is important to know that melanoma cancer staging can be complex. If you have any questions about the stage of your cancer or what it means for your treatment ask your doctor to explain it in a way you understand.

Melanoma has five stages: 0, I, II, III, IV

• Early melanoma is defined as stage I and stage II disease.
• Advanced melanoma is defined as stage III and stage IV disease.


STAGE 0 (MELANOMA IN SITU)

melanoma stage 0 in situ

In stage 0, abnormal melanocytes are found in the epidermis, the very top of the skin and have not spread to the dermis (the second layer of skin below the epidermis). It has not spread to lymph nodes or distant sites. Stage 0 is also called melanoma in situ.

Surgery to remove the melanoma and a border of normal skin completes treatment. The prognosis is excellent at this stage. Ongoing monitoring by a dermatologist is recommended at least annually for life, with regular monthly skin self-checks by the patient.

Stage I

Stage I melanoma

In stage I, cancer has formed. The cancer has not spread to nearby lymph nodes or distant sites. Stage I is divided into stages IA and IB.

Stage IA: In stage IA, the tumour is up to 1 mm thick, with or without ulceration.

Stage IB: In stage IB, the tumour is more than 1 mm but not more than 2 mm thick, with no ulceration.

Treatment of stage I includes a second surgery to remove a wider border of normal skin around the biopsy site (a wide local excision). In some cases, a sentinel lymph node biopsy may be recommended. Ongoing monitoring by a dermatologist is recommended at least annually for life, with regular monthly skin self-checks by the patient.

Stage II

Stage 2 melanoma

In stage II, the cancer has not spread to nearby lymph nodes or to distant sites. Stage II is divided into levels IIA, IIB, and IIC.

• Stage IIA: In stage IIA, the tumour is either:
– more than 1 mm but not more than 2 mm thick, with ulceration; or
– more than 2 mm but not more than 4 mm thick, with no ulceration.

• Stage IIB: In stage IIB, the tumour is either:
– more than 2 mm but not more than 4 mm thick, with ulceration; or
– more than 4 mm thick, with no ulceration.

• Stage IIC: In stage IIC, the tumour is more than 4 mm thick, with ulceration.

Treatment of stage II includes a second surgery to remove a wider border of normal skin around the biopsy site (wide local excision). The risk of recurrence, or return of the melanoma, or spread to another part of the body, is moderate in stage IIA. Some people, with larger tumours (stage IIB or IIC), have a higher risk of recurrence and may benefit from additional treatments. Sentinel lymph node biopsy is recommended for these patients to provide loco-regional control and to identify patients who may benefit from adjuvant therapy and/or entry into adjuvant clinical trials. SLNB does provide a melanoma-specific survival benefit if the sentinel node contains melanoma metastases.

Stage III

Stage 3 melanoma

In stage III melanoma has spread to nearby lymph vessels or lymph nodes. The tumour may be any thickness, with or without ulceration. Stage III is divided into four levels – A, B, C and D.

Stage IIIA – the primary melanoma is no more than 2 mm thick. It may or may not be ulcerated. It has spread to nor more than 3 lymph nodes detected by pathology (not palpable nodes). It has not spread to distant sites.

Stage IIIB – Either the primary melanoma site cannot be found and it has spread to only one lymph node or it has spread to very small areas of nearby skin (satellite metastasis) or lymphatic vessels, without spreading to distant sites; OR

The melanoma primary is no more than 4 mm and may or may not be ulcerated. It has spread to up to three lymph nodes or to very small areas of nearby skin (satellite tumours) or lymphatic channels. It has not spread to distant sites.

Stage IIIC – The primary melanoma site cannot be found AND it has spread to up to 4 or more lymph nodes OR it has spread to 2 or more lymph nodes and to very small areas of nearby skin (satellite metastasis) or lymphatic vessels, without spreading to distant sites; OR

The melanoma primary is no more than 4 mm and may or may not be ulcerated. It has spread to one or more lymph nodes or to very small areas of nearby skin (satellite tumours) or lymphatic channels or lymph nodes clumped together. It has not spread to distant sites; OR

The melanoma is between 2.1 mm and 4 mm and may or may not be ulcerated AND has spread to one or more lymph nodes or has spread to very small areas of nearby skin (satellite tumours) or lymphatic channels or lymph nodes clumped together. It has not spread to distant sites; OR

The melanoma is thicker than 4 mm, is ulcerated has spread to no more than 3 lymph nodes or to very small areas of nearby skin (satellite tumours) or lymphatic channels. It has not spread to distant sites.

Stage IIID – The primary melanoma is thicker than 4 mm, is ulcerated AND has spread to 4 or more lymph nodes OR has spread to very small areas of nearby skin (satellite tumours) or lymphatic channels. It has not spread to distant sites.

Treatment of stage III may include a wider border of normal skin around the biopsy site. Sentinel lymph node biopsy is recommended for these patients to provide loco-regional control and to identify patients who may benefit from adjuvant therapy, radiation and/or entry into adjuvant clinical trials. Adjuvant therapy following biopsy and surgery may be recommended and is discussed in our treatment section below.

Stage IV

Stage 4 melanoma

In stage IV, the cancer can be any thickness and might or might not be ulcerated. It may or may not have spread to nearby lymph nodes, but has spread to other distant sites in the body, such as the lung, liver, brain, bone, soft tissue, or gastrointestinal (GI) tract. Cancer may have spread to places in the skin far away from where it first started.

Treatment of Stage IV involves a discussion with your oncologist for available treatments and possibility of participating in clinical trials.

Melanoma Treatments

Learn more about the treatment options for melanoma

Melanoma Support

The Melanoma Network of Canada has a number of free services for patients, caregivers and healthcare professionals.

Melanoma Resources

Our leading-edge publications have been written with the help of specialists in oncology, surgery and dermatology. Useful for melanoma patients, caregivers and health care professionals.

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