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As you read through the text you will find some words in boldface. These are words that are defined and discussed in the Glossary. Click on a bolded word to access the definition.

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If you have melanoma, the treatment of your melanoma is based upon a rational plan developed by your physicians. The foundation of treatment planning is staging—the determination of what stage the tumor has reached in its growth.

Your physician must know if the primary melanoma is confined to the local area where it was found, if wider excision of the local site is indicated to assure removal of all tumor cells, and if melanoma cells have spread (metastasis) to lymph nodes or to distant organs such as liver, intestines, brain, lungs or bone. Unless the original or subsequent biopsy clearly shows that the melanoma was confined to its local site, had not invaded deeper tissues, and all melanoma cells were removed with the biopsy specimen(s), more tests may be necessary to stage the melanoma. These tests may include diagnostic imaging by X-ray, computed tomography (CT), magnetic resonance imaging (MRI), or radio-isotopic bone or organ scans. Additional biopsy also may be necessary—for example, biopsy of nearby (regional) lymph nodes to determine if they contain metastasized melanoma cells. (Click on sentinel node biopsy in the Glossary and in MelanomaNet Edition #1 for a description of an advanced form of lymph node biopsy). Your physicians will determine which tests are essential to effectively determine the stage of the melanoma. In general, additional testing for metastatic disease is not useful in the absence of signs and/or symptoms.

When all tests are completed and results analyzed, the melanoma will be staged according to a widely accepted staging system used in the United States and other countries. A system used in the U.S. and accepted in most other countries is that of the American Joint Commission on Cancer (AJCC). The AJCC system described here will be phased out in 2002, when a new but similar syatem will be adopted. The new system may already be in use in a few centers.

On the basis of results from the diagnostic tests, the AJCC classification system renders (1) a pathologist’s classification of the melanoma by its site, thickness, and metastasis, and (2) a clinical staging scheme for treatment planning. Stages of melanoma correlate with statistical data on risk for recurrence or death from the disease. Survival estimates are comparable to insurance actuarial tables—they are aggregates of compiled data that can be used to make generalized predictions but not predictions specific to an individual patient. Survival statistics show that higher stages of melanoma are associated with higher risk for death from the disease.

The pathologist’s AJCC classification is called the TNM classification:

T = Tumor

N = Node

M = Metastasis

Under the T (Tumor) classification, a melanoma is described in thickness ranging from T0 (no evidence of primary tumor) and Tis ( tumor in-situ, meaning the tumor is only in the epidermis), to T4 (equating to 4 millimeters or greater thickness in Breslow thickness classification scheme (Click on thickness for an explanation of the Breslow thickness classification system, and on Clark level for explanation of a system that assesses melanoma penetration into the skin and deeper tissues).

Under the N (Node) classification, a melanoma is described by its metastasis to lymph nodes, ranging from N0 (no evidence of metastasis to lymph nodes) to N1 (local node metastasis) to N2 (significant lymph node metastasis). The N2 classification is subdivided into N2, N2a, N2b and N2c to reflect increasing severity of disease.

Under the M (Metastasis) classification, a melanoma is described by its metastasis to distant organs, ranging from M0 (no evidence of metastasis to distant organs) to M1a (metastasis to distant skin and subcutaneous tissue) and M1b (metastasis to internal organs such as liver, intestines, brain and bone, and distant lymph nodes).

Five-year survival rates (i.e., survival for at least 5 years after treatment for invasive melanoma) decrease with increasing stage and severity of disease. Increasing thickness of a melanoma is associated with decreasing survival rates, and increased number of tumor-positive lymph nodes is associated with decreasing survival rates.

On the basis of the TNM classification, your physicians can develop a staging system for treatment planning:

The I-IV classification provides a ground plan for treatment. Treatment is, of course, individualized to the needs of each patient. A treatment plan may be modified during its course, depending on an individual patient’s response to treatment.

In the most general terms, treatment at States I-IV may include:

Stage I:

Local surgery at the melanoma site to assure that all tumor tissue is removed.

Stage II:

Local, but more extensive, surgery at the melanoma site with removal of as much surrounding tissue as necessary to assure that all tumor tissue is removed. A small skin graft may be necessary to cover the site of surgically removed tissue.

Removal of regional lymph nodes if indicated by test results.

Trial of systemic or adjuvant chemotherapy or biotherapy (see MelanomaNet Edition #2 for a discussion of biotherapy), if indicated by test results and your physicians.

Stage III:

Surgical excision at the melanoma site, removing as much tissue as necessary to assure that all tumor tissue is removed. Local skin grafting may be necessary after surgery.

Lymph node biopsy and removal of regional lymph nodes if indicated by test results.

Trial of adjuvant chemotherapy and biotherapy.

Surgical removal of metastasized lymph nodes, and a single metastatic lesion in a distant organ if possible.

Systemic and/or adjuvant biotherapy; heated chemotherapy; chemotherapy or biotherapy directed locally to tumor(s).

Radiation therapy to ease symptoms of metastatic melanoma.

The AJCC staging system may vary slightly at different hospitals and medical centers, and some older but similar systems may still be in use, but the overall pattern will usually be similar to the system described in this edition of MelanomaNet.

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