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    Patent Pending

    TNM Staging for Melanoma

    Stages melanoma based on tumor, lymph node, and metastasis characteristics.
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    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with confirmed melanoma diagnosed by biopsy.

    • Requires pathologic specimen for evaluation, so lymph node status cannot be adequately assessed until after surgical resection.
    • TNM staging is frequently updated based on new evidence. The AJCC 8th edition is expected to be implemented into clinical practice on January 1, 2018. Until then, all tumors should be staged according to the 7th edition.

    TNM staging is the standard staging system used by surgeons, medical oncologists, and dermatologists to prognosticate and communicate about patients.

    No evidence of primary tumor
    Melanoma in situ
    Thickness ≤1.0 mm
    Thickness 1.01–2.0 mm
    Thickness 2.01–4.0 mm
    Thickness >4.0 mm
    Cannot be assessed (e.g. curettaged or severely regressed melanoma)
    No regional metastases detected
    1 node
    2–3 nodes
    ≥4 metastatic nodes, or matted nodes, or in transit met(s) or satellites with metastatic nodes
    Cannot be assessed (e.g. previously removed for other reason)
    No detectable evidence of distant metastases and normal serum LDH
    Metastases to skin, subcutaneous, or distant lymph nodes and normal serum LDH
    Lung metastases and normal serum LDH
    Metastases to all other visceral sites with normal serum LDH, or distant metastases to any site with elevated serum LDH

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    National Comprehensive Cancer Network (NCCN) guidelines use TNM staging for biopsy-confirmed cases of melanoma.

    Management

    All patients with biopsy-confirmed melanoma should be referred to a surgeon and/or medical oncologist.

    Critical Actions

    • Per NCCN guidelines, when the sentinel lymph node is positive, complete lymph node dissection should be discussed.
      • When the sentinel lymph node is positive by pathology only, systemic imaging is indicated to evaluate specific signs or symptoms.
      • When the sentinel lymph node is clinically positive, systemic imaging should be performed for baseline staging.

    Formula

    Primary tumor (T)

    Tx

    Cannot be assessed (e.g. curettaged or severely regressed melanoma)

    T0

    No evidence of primary tumor

    Tis

    Melanoma in situ

    T1

    Thickness ≤1.0 mm

    T1a: no ulceration and mitosis <1/mm2

    T1b: ulceration or mitoses ≥1/mm2

    T2

    Thickness 1.01–2.0 mm

    T2a: no ulceration

    T2b: ulceration

    T3

    Thickness 2.01–4.0 mm

    T3a: no ulceration

    T3b: ulceration

    T4

    Thickness >4.0 mm

    T4a: no ulceration

    T4b: ulceration

    Regional lymph nodes (N)

    Nx

    Cannot be assessed

    (e.g. previously removed for other reason)

    N0

    No regional metastases detected

    N1

    1 node

    N1a: micrometastasis1

    N1b: macrometastasis2

    N2

    2–3 nodes

    N2a: micrometastasis1

    N2b: macrometastasis2

    N2c: in transit met(s) or satellite(s) without metastatic nodes

    N3

    ≥4 metastatic nodes, or matted nodes, or in transit met(s) or satellites with metastatic nodes





    Distant metastasis (M)

    M0

    No detectable evidence of distant metastases and normal serum LDH

    M1a

    Metastases to skin, subcutaneous, or distant lymph nodes and normal serum LDH

    M1b

    Lung metastases and normal serum LDH

    M1c

    Metastases to all other visceral sites with normal serum LDH, or distant metastases to any site with elevated serum LDH

    1. Diagnosed after sentinel lymph node biopsy and completion lymphadenectomy (if performed).


    2. Clinically detectable nodal metastases confirmed by therapeutic lymphadenectomy or when nodal metastasis exhibits gross extracapsular extension.

    Facts & Figures

    Interpretation:

    Anatomic stage / prognostic groups

    Clinical staging3

    Pathologic staging4

    Stage 0

    Tis

    N0

    M0

    0

    Tis

    N0

    M0

    Stage IA

    T1a

    N0

    M0

    IA

    T1a

    N0

    M0

    Stage IB

    T1b

    N0

    M0

    IB

    T1b

    N0

    M0

    T2a

    N0

    M0

    T2a

    N0

    M0

    Stage IIA

    T2b

    N0

    M0

    IIA

    T2b

    N0

    M0

    T3a

    N0

    M0

    T3a

    N0

    M0

    Stage IIB

    T3b

    N0

    M0

    IIB

    T3b

    N0

    M0

     

    T4a

    N0

    M0

    T4a

    N0

    M0

    Stage IIC

    T4b

    N0

    M0

    IIC

    T4b

    N0

    M0

    Stage III

    Any T

    ≥N1

    M0

    IIIA

    T(1-4)a

    N1a

    M0

           

    T(1-4)a

    N2a

    M0

         

    IIIB

    T(1-4)b

    N1a

    M0

         

    T(1-4)b

    N2a

    M0

         

    T(1-4)a

    N1b

    M0

         

    T(1-4)a

    N2b

    M0

         

    T(1-4)a

    N2c

    M0

         

    IIIC

    T(1-4)b

    N1b

    M0

         

    T(1-4)b

    N2b

    M0

         

    T(1-4)b

    N2c

    M0

         

    Any T

    N3

    M0

    Stage IV

    Any T

    Any N

    M1

    IV

    Any T

    Any N

    M1

    3. Clinical staging includes microstaging of the primary melanoma and clinical/radiologic evaluation for metastases. By convention, it should be used after complete excision of the primary melanoma with clinical assessment for regional and distant metastases.

    4. Pathologic staging includes microstaging of the primary melanoma and pathologic information about the regional lymph nodes after partial or complete lymphadenectomy. Pathologic Stage 0 or Stage IA patients are the exception; they do not require pathologic evaluation of their lymph nodes.

    Dr. Daniel G. Coit

    About the Creator

    Daniel G. Coit, MD, FACS, is a surgical oncologist at Memorial Sloan Kettering Cancer Center. He is also a co-leader of the Melanoma Disease Management Team. Dr. Coit’s research interests include identifying high risk patients for melanoma recurrence and gastric cancer.

    To view Dr. Daniel G. Coit's publications, visit PubMed

    Content Contributors
    • Allison Betof, MD
    • Michael Postow, MD
    About the Creator
    Dr. Daniel G. Coit
    Content Contributors
    • Allison Betof, MD
    • Michael Postow, MD