a

a
l
e

M
f

o
AJCC classification - TNM,
2009,
t
n
preview of the new
2015
e
m
e
classification
g
n
i
s

e
t
a

d
p

e
th

a
n
a
M

Claus Garbe

Center for Dermatooncology

Department of Dermatology
University of Tbingen, Germany

o
n

a
m

AJCC Melanoma Staging System no

a
l
e

M
f

Primary tumor

Regional Metastasis

n
e

o
t

Distant Metastasis

m
e
g

Stages I/II
5-year-survival
97% - 53%

n
i
s

e
t
a

d
p

e
th

a
n
a
M

Stage III
5-year-survival
70% - 39%

Stage IV
5-year-survival
25% - 9%

a
m

a
l
e

o
n

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

E. Hlzle et al. 1993

a
Breslows tumor thickness and Clarks m
o
n
level of invasion
a
l
e
M
Clarks
Level
f
o
of
Invasion
t
n
e
Breslows
m
e
Tumor
g
a
Thickness
n
a
M
e
h
t
n
i
s
e
t
a
d
p
U
Measured
from stratum
corneum to
deepest tumor
formation at
the microscop
in millimeter

Level I: intraepidermal (in

situ)
Level II: few cells in
stratum papillare
Level III: fills stratum
papillare
Level IV: invades stratum
reticulare
Level V: invades
subcutaneous fat

a
m

a
l
e

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

o
n

a
m

a
l
e

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

o
n

TNM Classification 1987/1997 vs. 2002o

a
m

n
la

pT classif. 1987/1997

pT classification 2002

pTis

Melanoma in situ

pT1

pT1

TT 0.75 mm and level

II

pT2

TT 0.76 - 1.5 mm
and/or level III
TT 1.51 - 3.0 mm
and/or level IV

pT3b

TT 3.01 - 4.0 mm
and/or level IV

pT4a

TT > 4.0 mm and/or

level V

n
i
s

d
p

e
th

t
n

TT 1.00 mm
a: ulzeration and level
II/III
b: with ulzeration or
level IV/V

e
m
e
g

a
n
a
M

pT3a

e
t
a

f
o

e
M

pT2

TT 1.01-2.0mm
a: ulzeration
b: with ulzeration

pT3

TT 2.01-4.0mm
a: ulzeration
b: with ulzeration

pT4

TT > 4.0mm
a: ulzeration
b: with ulzeration

AJCC Classification 2002

a
m

T Classification
Clinical Stage
IA
IB

T
T1a
T1b
T2a
T2b
T3a
T3b
T4a
T4b

i
s

IIB

e
t
IICa
d
p
U

h
t
n

M
f

o
t
Tumor thickness
Ulc./Level
n
< 1 mm e
no ulc.
m
e
< 1g
mm
Ulc./Lev IV/V
a
1-2
mm
no ulc.
n
a

M
e

IIA

a
l
e

o
n

1-2 mm
2-4 mm
2-4 mm
> 4 mm
> 4 mm

ulc.
no ulc.
ulc.
no ulc.
ulc.

AJCC Classification 2009

a
m

a
l
e

o
n

p
U

M
T-classification main changes compared
to
f
o
2002
t
n
e
Main parameters remain Breslows
tumor
m
e
thickness and ulceration
g
a
n
Newly introducedawill be mitosis rate/mm in T1
M
e
Clarks level
of invasion is no longer a T parah
t
metern
i
s
e
t
a
d

AJCC Classification 2009

a
m

Tumor thickness und case fatality

a
l
e

o
n

M
f

o
t

n
e

m
e
g

n
i
s

e
th

a
n
a
M

e
t
a

d
p

J. Gershenwald 2009

AJCC Classification 2009

a
m

Tumor thickness and case fatality

a
l
e

o
n

M
f

o
t

n
e

m
e
g

n
i
s

e
th

a
n
a
M

e
t
a

d
p

J. Gershenwald 2009

AJCC Classification 2009

a
m

Mitoses/mm and case fatality

a
l
e

o
n

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

J. Gershenwald 2009

AJCC Classification 2009

a
m

Mitoses/mm und tumor thickness

a
l
e

o
n

M
f

o
t

n
e

m
e
g

n
i
s

e
th

a
n
a
M

e
t
a

d
p

J. Gershenwald 2009

a
Cox regression analysis for 10,233 melanoma patientsm
o
with localized melanoma including mitotic raten
a
l
e
M
f
o
t
n
e
m
e
g
a
n
a
M
e
h
t
n
i
s
e
t
a
d
p
U
Variable

Chi-square
values
(1 d.f.)

HR

95%
CI

Tumor thickness

84.6

<0.0001

1.25

1.91 1.31

Ulceration

47.2

<0.0001

1.56

1.38 1.78

Clarks Level

8.2

0.0041

1.15

1.04 1.26

Mitotic Rate

79.1

<0.0001

1.26

1.20 1.32

Site

29.1

<0.0001

1.38

1.23 1.54

Gender

32.4

<0.0001

0.70

0.62 0.79

Age

40.8

<0.0001

1.16

1.11 1.22

Melanoma of the Skin, 7th Edition AJCC Manual for Staging of Cancer
In Press, 2009.

AJCC Classification 2009

a
m

T Classification

M
f

a
l
e

o
t
Clinical stage T
Tumor thickness Ulc./Level
n
e
IA
T1a < 1 mm
no ulc./< 1m.
m ulc./ 1m./mm
IB
T1b < 1 mm e
g
T2a 1-2 mm
no ulc.
a
n
IIA
T2b 1-2
mm
ulc.
a
T3a M
2-4 mm
no ulc.
e
hT3b 2-4 mm
IIB
ulc.
t
n T4a > 4 mm
no ulc.
i
IIC es
T4b > 4 mm
ulc.
t
a
d
p

o
n

AJCC Classification 2009

a
m

a
l
e

o
n

p
U

M
N-Classification main changes inf
o
comparison to 2002
t
n
e
Micrometastasis can be detected
with HE
m
e
staining or with immunohistochemistry
g
a
n
There is no lowerathreshold for the diagnosis of
M
micrometastasis,
one metastatic cell is enough
e
h
t
Soft tissue
metastases of unknown primary
n
i
melanoma
are classified as stage III disease
s
e
t
a
d

AJCC Classification 2009

a
m

M
f

N-Classification
N

Number of metastatic lymp nodes.

N1

1 lymph node

N2

2-3 lymph nodes

N3

n
i
s

o
t

n
e

Kind of metastases

m
e
g

a
n
a
M

4 or more lymph nodes or intransit/satellite metastases with met.

lymph nodes

e
t
a

d
p

e
th

a
l
e

o
n

a: Micrometastases
b: Macrometastases
a: Micrometastases
b: Macrometastases
c: intransit/satellite
metastases without met.
lymph nodes

AJCC Classification 2009

a
m

a
l
e

o
n

M
f

Number of metastatic lymph nodes and case fatality

o
t

n
e

m
e
g

n
i
s

e
th

a
n
a
M

e
t
a

d
p

J. Gershenwald 2009

AJCC Classification 2009

a
m

Stage III and TNM classification

IIIA
IIIB

n
IIIC
i
s

e
t
a

d
p

T1-4a
T1-4a
T1-4b
T1-4b
T1-4a
T1-4a
T1-4a/b
T1-4b
T1-4b
Each T

e
th

N1a
N2a
N1a
N2a
N1b
N2b
N2c
N1b
N2b
N3

a
n
a
M

m
e
g

n
e

o
t

M0
M0
M0
M0
M0
M0
M0
M0
M0
M0

M
f

a
l
e

o
n

AJCC Classification 2009

a
m

a
l
e

o
n

M
f

Melanoma of unknown primary tumor

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

J. Gershenwald 2009

AJCC Classification 2009

a
m

a
l
e

o
n

M
f

MUP clinical implications

o
t

n
e

m
e
g

Cutaneous and subcutaneous metastases and lymph

node metastases of MUP are classified as stage III

a
n
a
M

Radical surgical therapy is indicated as in regional

metastases

e
th

Patients should be offered an adjuvant treatment

n
i
s

e
t
a

d
p

AJCC Classification 2009

a
m

M
f

M-Classification
M1a

M1b
M1c

n
i
s

e
t
a

d
p

Localisation
Distant skin
metastases,
subcutaneous or
lymph node
metastases
Lung metastases
Other visceral
metastases
Each distant
metastasis

o
t

n
e

m
e
g

e
th

a
l
e

Serum LDH
Normal

a
n
a
M

Normal
Normal
Elevated

o
n

AJCC Classification 2009

a
m

a
l
e

o
n

M
f

Kind of distant metastasis and case fatality

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

J. Gershenwald 2009

AJCC Classification 2015

a
m

a
l
e

o
n

M
f

o
t

n
e

m
e
g

a
n
a
M

Methods and Findings: We analyzed 1,834 sentinel nodes from 1,027 patients with
ultrasound node-negative melanoma who underwent sentinel node biopsy between
February 8, 2000, and June 19, 2008, by histopathology including immunohistochemistry
and quantitative immunocytology. For immunocytology we recorded the number of
disseminated cancer cells (DCCs) per million lymph node cells (DCC density [DCCD])
after disaggregation and immunostaining for the melanocytic marker gp100.

n
i
s

e
t
a

d
p

e
th

Ulmer A, et al. PLOS Medicine 2014

a
m

a
l
e

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

o
n

a
m

a
l
e

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

Ulmer A, et al. PLOS Medicine 2014

o
n

a
m

a
l
e

o
n

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

Ulmer A, et al. PLOS Medicine 2014

a
m

a
l
e

o
n

M
f

o
t

n
e

m
e
g

n
i
s

e
t
a

d
p

e
th

a
n
a
M

Ulmer A, et al. PLOS Medicine 2014

a
m

AJCC Melanoma Staging System no

a
l
e

M
f

Primary tumor

Regional Metastasis

n
e

o
t

Distant Metastasis

m
e
g

Stages I/II
5-year-survival
97% - 53%

n
i
s

e
t
a

d
p

e
th

a
n
a
M

Stage III
5-year-survival
70% - 39%

Stage IV
5-year-survival
25% - 9%