Staging Becomes the Foundation of Your Treatment Plan

Once your diagnosis is made, a process called staging is used to determine the extent of the cancer within your body. This section is designed to help you better understand how staging enables your doctor to select the treatment options that will be most effective for you.

Melanoma is usually staged twice. First, your doctor considers the results of your physical exam and skin biopsy to assign a clinical stage. During a more extensive procedure, the lesion (or as much of it as possible) is removed along with some healthy tissue surrounding it. In a different procedure, some lymph nodes may be removed. After reviewing these specimens with and without a microscope and noting key characteristics, a pathologist also considers results from lymph node biopsies and other tissue that was examined. Then a pathologic stage is assigned. Because the pathologic stage is based on more details about the melanoma, this staging is the most accurate and is important in determining the best treatment options for your diagnosis.

Both the clinical and pathologic stages of melanoma are classified according to the tumor, node, metastasis (TNM) system developed by the American Joint Committee on Cancer (AJCC). This system uses the size and location of the tumor (T), whether cancer cells are found in nearby lymph nodes (N) and whether the cancer has metastasized, or spread, to other parts of the body (M). The thickness of the primary melanoma is used to classify the melanoma in the T category. Additionally, each T classification is further divided into groups according to whether ulceration (a break in the outer layer of skin over the melanoma) is absent (subcategory a) or present (subcategory b). The node (N) classification is used to describe how many lymph nodes contain melanoma cells and includes subcategories to describe the extent of cancer cells in the lymph nodes.

The results of the TNM analysis are then used to determine the overall stage of melanoma for each individual. Stages range from 0 to IV (see Tables 1 and 2).

More About Your Pathology Report

With today’s emphasis on personalizing treatment for each person’s cancer, including its genomic or molecular abnormalities, pathology report results are integral to melanoma treatment. Doctors have more options for treating melanoma by subtype now that drug therapies are available for targeting specific mutations, but these therapies can only be used if they are confirmed with genomic or molecular testing.

Along with your diagnosis and histologic subtype (classification based on the melanoma’s microscopic features), your pathology report may include some or all of the following:

Thickness: how deep the tumor has grown into the skin

Ulceration status: whether the tumor’s top skin layer is present and intact (not ulcerated) or broken or missing (ulcerated)

Dermal mitotic rate: how many melanoma cells are actively growing and dividing

Peripheral margin status: the presence or absence of cancer cells in the normal-looking tissue that was removed from around the tumor

Deep margin status: the presence or absence of cancer cells in the normal-looking tissue that was removed from underneath the tumor

Microsatellitosis: the presence of tiny satellite tumors that have spread to skin near the first melanoma tumor. These can only be seen with a microscope.

Regression: the presence of lymphocytes (a type of white blood cell) and scar-like changes that suggest a person’s immune system is attacking the melanoma

Location: where the tumor is found

Tumor-infiltrating lymphocytes: the presence of white blood cells that may be present in a primary melanoma

Vertical growth phase: evidence of tumor growth down into the skin

Angiolymphatic invasion: whether melanoma has grown into blood or lymph vessels

Neurotropism: the presence of melanoma cells in or around the nerves in the skin

Ask your doctor to explain how these findings affect your treatment options. You can also request a copy of your pathology report.


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