Chapter 083. Cancer of the Skin (Part 3)

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Prognostic Factors The most important prognostic factor is the stage at the time of presentation. Fortunately, most melanomas are diagnosed in clinical stages I and II. The revised American Joint Committee on Cancer (AJCC) staging system for melanoma is based on microscopic primary tumor depth (Breslow's thickness), presence of ulceration, evidence of nodal involvement, and presence of metastatic disease to internal sites (Table 83-3). Certain anatomic sites may affect the prognosis. The favorable sites appear to be the forearm and leg (excluding feet), while unfavorable sites include scalp, hands, feet, and mucous membranes. In general, women with stage I or...

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Chapter 083. Cancer of the Skin (Part 3) Prognostic Factors The most important prognostic factor is the stage at the time of presentation. Fortunately, most melanomas are diagnosed in clinical stages I and II. The revised American Joint Committee on Cancer (AJCC) staging system for melanoma is based on microscopic primary tumor depth (Breslow's thickness), presence of ulceration, evidence of nodal involvement, and presence of metastatic disease to internal sites (Table 83-3). Certain anatomic sites may affect the prognosis. The favorable sites appear to be the forearm and leg (excluding feet), while unfavorable sites include scalp, hands, feet, and mucous membranes. In general, women with stage I or II disease have a better survival than men, perhaps in part because of earlier diagnosis; women frequently have melanomas on the lower leg, where self-recognition is more likely and prognosis is better. Older individuals, especially men over 60, have poorer prognoses. This finding has been
explained in part by a tendency toward later diagnosis (and thus thicker tumors) in men and by a higher proportion in men of acral melanomas (palmar-plantar), which have a poorer prognosis. Melanoma may recur after many years. About 10– 15% of first-time recurrences develop >5 years after treatment of the original lesion. The time to recurrence varies inversely with tumor thickness. An alternative prognostic scheme for clinical stages I and II melanoma, proposed by Clark, is based on the anatomic level of invasion in the skin. Level I is intraepidermal (in situ); level II penetrates the papillarydermis; level III spans the papillary dermis; level IV penetrates the reticular dermis; and level V penetrates into the subcutaneous fat. The 5-year survival for these stages averages 100, 95, 82, 71, and 49%, respectively. Table 83-3 Prognosis of Melanoma by Thickness (Breslow) and Revised AJCC Stages: 5-Year Survival Rates AJCC Thickness, Ulceration Nodal Distant Stage mm Disease Metastases 0 In situ N/A No No IA
IB 4.0 No No No IIC >4.0 Yes No No IIIA Any No Yes 1 node No w/microscopic disease
2–3 No nodes w/microscopic disease IIIB Any Yes 1 node No w/microscopic disease Any Yes 2–3 No nodes w/microscopic disease Any No 1 node No w/macroscopic disease Any No 2–3 No nodes w/macroscopic
disease Any Any In transit No or satellite disease w/out nodal disease IIIC Any Yes 1 node No w/macroscopic disease Yes 2–3 No nodes w/macroscopic disease Any ≥4 No metastatic or matted nodes, or in transit mets/satellites
or metastatic nodes IV Any Any Any Yes Note: AJCC, American Joint Commission for Cancer. Natural History Melanomas may spread by the lymphatic channels or the bloodstream. The earliest metastases are often to regional lymph nodes. Lymphadenectomy may control early regional disease. Liver, lung, bone, and brain are common sites of hematogenous spread, but unusual sites, such as the anterior chamber of the eye, may also be involved. Once metastatic disease is established, cure is unlikely.