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Journal of Clinical Oncology, Vol 19, Issue 16 (August), 2001: 3635-3648
© 2001 American Society for Clinical Oncology

Final Version of the American Joint Committee on Cancer Staging System for Cutaneous Melanoma

By Charles M. Balch, Antonio C. Buzaid, Seng-Jaw Soong, Michael B. Atkins, Natale Cascinelli, Daniel G. Coit, Irvin D. Fleming, Jeffrey E. Gershenwald, Alan Houghton, Jr, John M. Kirkwood, Kelly M. McMasters, Martin F. Mihm, Donald L. Morton, Douglas S. Reintgen, Merrick I. Ross, Arthur Sober, John A. Thompson, John F. Thompson

From the Johns Hopkins Medical Institutions, Baltimore, MD; American Society of Clinical Oncology, Alexandria, VA; Hospital Sirio Libanes, San Paulo, Brazil; University of Alabama at Birmingham, Birmingham, AL; Beth Israel Deaconess Medical Center and Massachusetts General Hospital, Boston, MA; Istituto Nazionale Tumori and World Health Organization Melanoma Program, Milan, Italy; Memorial Sloan-Kettering Cancer Center, New York, NY; Methodist Hospital Cancer Center, Memphis, TN; University of Texas, M.D. Anderson Cancer Center, Houston, TX; University of Pittsburgh Medical Center, Pittsburgh, PA; University of Louisville Medical Center, Louisville, KY; John Wayne Cancer Institute, Santa Monica, CA; H. Lee Moffit Cancer Center, University of South Florida, Tampa, FL; University of Washington Medical Center, Seattle, WA; and Sydney Melanoma Unit, University of Sydney, Sydney, New South Wales, Australia.

Address reprint requests to Charles M. Balch, MD, American Society of Clinical Oncology, 1900 Duke St, Ste 200, Alexandria, VA 22314; email: balchc{at}asco.org

PURPOSE: To revise the staging system for cutaneous melanoma under the auspices of the American Joint Committee on Cancer (AJCC).

MATERIALS AND METHODS: The prognostic factors analysis described in the companion publication (this issue), as well as evidence from the published literature, was used to assemble the tumor-node-metastasis criteria and stage grouping for the melanoma staging system.

RESULTS: Major changes include (1) melanoma thickness and ulceration but not level of invasion to be used in the T category (except for T1 melanomas); (2) the number of metastatic lymph nodes rather than their gross dimensions and the delineation of clinically occult (ie, microscopic) versus clinically apparent (ie, macroscopic) nodal metastases to be used in the N category; (3) the site of distant metastases and the presence of elevated serum lactic dehydrogenase to be used in the M category; (4) an upstaging of all patients with stage I, II, and III disease when a primary melanoma is ulcerated; (5) a merging of satellite metastases around a primary melanoma and in-transit metastases into a single staging entity that is grouped into stage III disease; and (6) a new convention for defining clinical and pathologic staging so as to take into account the staging information gained from intraoperative lymphatic mapping and sentinel node biopsy.

CONCLUSION: This revision will become official with publication of the sixth edition of the AJCC Cancer Staging Manual in the year 2002.


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E. L. Korn, P.-Y. Liu, S. J. Lee, J.-A. W. Chapman, D. Niedzwiecki, V. J. Suman, J. Moon, V. K. Sondak, M. B. Atkins, E. A. Eisenhauer, et al.
Meta-Analysis of Phase II Cooperative Group Trials in Metastatic Stage IV Melanoma to Determine Progression-Free and Overall Survival Benchmarks for Future Phase II Trials
J. Clin. Oncol., February 1, 2008; 26(4): 527 - 534.
[Abstract] [Full Text] [PDF]

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P Savoia, S Osella-Abate, A Comessatti, T Nardo, C Marchio, D Pacchioni, P Quaglino, and M G Bernengo
Traditional urinary cytology and tyrosinase RT-PCR in metastatic melanoma patients: correlation with clinical status
J. Clin. Pathol., February 1, 2008; 61(2): 179 - 183.
[Abstract] [Full Text] [PDF]

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 JCOHome page
C. M. Balch and S.-j. Soong
Predicting Outcomes in Metastatic Melanoma
J. Clin. Oncol., January 10, 2008; 26(2): 168 - 169.
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 JCOHome page
J. A. Zell, P. Cinar, M. Mobasher, A. Ziogas, F. L. Meyskens Jr, and H. Anton-Culver
Survival for Patients With Invasive Cutaneous Melanoma Among Ethnic Groups: The Effects of Socioeconomic Status and Treatment
J. Clin. Oncol., January 1, 2008; 26(1): 66 - 75.
[Abstract] [Full Text] [PDF]

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 Arch DermatolHome page
D. S. Cassarino, E. S. Cabral, R. V. Kartha, and S. M. Swetter
Primary Dermal Melanoma: Distinct Immunohistochemical Findings and Clinical Outcome Compared With Nodular and Metastatic Melanoma
Arch Dermatol, January 1, 2008; 144(1): 49 - 56.
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 JCOHome page
E. H. Boesen, S. H. Boesen, K. Frederiksen, L. Ross, K. Dahlstrom, G. Schmidt, J. Naested, C. Krag, and C. Johansen
Survival After a Psychoeducational Intervention for Patients With Cutaneous Malignant Melanoma: A Replication Study
J. Clin. Oncol., December 20, 2007; 25(36): 5698 - 5703.
[Abstract] [Full Text] [PDF]

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 PsychosomaticsHome page
E. Boesen, S. Boesen, S. Christensen, and C. Johansen
Comparison of Participants and Non-Participants in a Randomized Psychosocial Intervention Study Among Patients With Malignant Melanoma
Psychosomatics, December 1, 2007; 48(6): 510 - 516.
[Abstract] [Full Text] [PDF]

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 JCOHome page
N. J. Ives, R. L. Stowe, P. Lorigan, and K. Wheatley
Chemotherapy Compared With Biochemotherapy for the Treatment of Metastatic Melanoma: A Meta-Analysis of 18 Trials Involving 2,621 Patients
J. Clin. Oncol., December 1, 2007; 25(34): 5426 - 5434.
[Abstract] [Full Text] [PDF]

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 Clin. Cancer Res.Home page
S. Ugurel, R. Houben, D. Schrama, H. Voigt, M. Zapatka, D. Schadendorf, E. B. Brocker, and J. C. Becker
Microphthalmia-Associated Transcription Factor Gene Amplification in Metastatic Melanoma Is a Prognostic Marker for Patient Survival, But Not a Predictive Marker for Chemosensitivity and Chemotherapy Response
Clin. Cancer Res., November 1, 2007; 13(21): 6344 - 6350.
[Abstract] [Full Text] [PDF]

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 JCOHome page
A. A. Tarhini, J. M. Kirkwood, W. E. Gooding, C. Cai, and S. S. Agarwala
Durable Complete Responses With High-Dose Bolus Interleukin-2 in Patients With Metastatic Melanoma Who Have Experienced Progression After Biochemotherapy
J. Clin. Oncol., September 1, 2007; 25(25): 3802 - 3807.
[Abstract] [Full Text] [PDF]

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 JRSMHome page
S. Retsas
Sentinel node biopsy confers no added protection to patients with melanoma
J R Soc Med, August 1, 2007; 100(8): 391 - 392.
[Full Text] [PDF]

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 Arch SurgHome page
J. K. Wall, M. Florero, N. A. Accortt, R. Allen, M. Kashani-Sabet, E. Morita, and S. P. L. Leong
Impact of Multiple Lymphatic Channel Drainage to a Single Nodal Basin on Outcomes in Melanoma
Arch Surg, August 1, 2007; 142(8): 753 - 758.
[Abstract] [Full Text] [PDF]

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 Clin. Cancer Res.Home page
Y. Wang, D. L. Dai, M. Martinka, and G. Li
Prognostic Significance of Nuclear ING3 Expression in Human Cutaneous Melanoma
Clin. Cancer Res., July 15, 2007; 13(14): 4111 - 4116.
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 Clin. Cancer Res.Home page
B. Elliott, R. A. Scolyer, S. Suciu, S. Lebecque, D. Rimoldi, O. Gugerli, E. Musat, R. N. Sharma, D. Lienard, U. Keilholz, et al.
Long-Term Protective Effect of Mature DC-LAMP+ Dendritic Cell Accumulation in Sentinel Lymph Nodes Containing Micrometastatic Melanoma
Clin. Cancer Res., July 1, 2007; 13(13): 3825 - 3830.
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 Am. J. Pathol.Home page
S. Jackowski, M. Janusch, E. Fiedler, W. C. Marsch, E. J. Ulbrich, G. Gaisbauer, J. Dunst, D. Kerjaschki, and P. Helmbold
Radiogenic Lymphangiogenesis in the Skin
Am. J. Pathol., July 1, 2007; 171(1): 338 - 348.
[Abstract] [Full Text] [PDF]

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 JAMAHome page
C. R. Bradford and P. A. Levine
Incidence and Prognosis of Cutaneous Melanoma Involving the Head and Neck
JAMA, June 20, 2007; 297(23): 2628 - 2629.
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I. D. Davis, B. K. Skrumsager, J. Cebon, T. Nicholaou, J. W. Barlow, N. P. H. Moller, K. Skak, D. Lundsgaard, K. S. Frederiksen, P. Thygesen, et al.
An Open-Label, Two-Arm, Phase I Trial of Recombinant Human Interleukin-21 in Patients with Metastatic Melanoma
Clin. Cancer Res., June 15, 2007; 13(12): 3630 - 3636.
[Abstract] [Full Text] [PDF]

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 JCOHome page
J. N. Cormier, Y. Xing, M. Ding, S. B. Cantor, K. J. Salter, J. E. Lee, P. F. Mansfield, J. E. Gershenwald, and M. I. Ross
Cost Effectiveness of Adjuvant Interferon in Node-Positive Melanoma
J. Clin. Oncol., June 10, 2007; 25(17): 2442 - 2448.
[Abstract] [Full Text] [PDF]

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 Ann OncolHome page
E de Vries, S Houterman, M. Janssen-Heijnen, T Nijsten, S. van de Schans, A. Eggermont, and J. Coebergh
Up-to-date survival estimates and historical trends of cutaneous malignant melanoma in the south-east of The Netherlands
Ann. Onc., June 1, 2007; 18(6): 1110 - 1116.
[Abstract] [Full Text] [PDF]

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 JCOHome page
H. Schmidt, S. Suciu, C. J.A. Punt, M. Gore, W. Kruit, P. Patel, D. Lienard, H. von der Maase, A. M.M. Eggermont, and U. Keilholz
Pretreatment Levels of Peripheral Neutrophils and Leukocytes As Independent Predictors of Overall Survival in Patients With American Joint Committee on Cancer Stage IV Melanoma: Results of the EORTC 18951 Biochemotherapy Trial
J. Clin. Oncol., April 20, 2007; 25(12): 1562 - 1569.
[Abstract] [Full Text] [PDF]

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 Arch DermatolHome page
M. L. Pennie, S. L. Soon, J. B. Risser, E. Veledar, S. D. Culler, and S. C. Chen
Melanoma Outcomes for Medicare Patients: Association of Stage and Survival With Detection by a Dermatologist vs a Nondermatologist
Arch Dermatol, April 1, 2007; 143(4): 488 - 494.
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 Mayo Clin Proc.Home page
S. N. Markovic, L. A. Erickson, R. D. Rao, R. H. Weenig, B. A. Pockaj, A. Bardia, C. M. Vachon, S. E. Schild, R. R. McWilliams, J. L. Hand, et al.
Malignant Melanoma in the 21st Century, Part 2: Staging, Prognosis, and Treatment
Mayo Clin. Proc., April 1, 2007; 82(4): 490 - 513.
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 JCOHome page
P. A. Gimotty, D. E. Elder, D. L. Fraker, J. Botbyl, K. Sellers, R. Elenitsas, M. E. Ming, L. Schuchter, F. R. Spitz, B. J. Czerniecki, et al.
Identification of High-Risk Patients Among Those Diagnosed With Thin Cutaneous Melanomas
J. Clin. Oncol., March 20, 2007; 25(9): 1129 - 1134.
[Abstract] [Full Text] [PDF]

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 NEJMHome page
J. F. Thompson, F. S. Hodi, and A. Zembowicz
Case 2-2007 -- A 49-Year-Old Woman with a Pigmented Lesion on the Arm
N. Engl. J. Med., January 18, 2007; 356(3): 285 - 292.
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 Arch DermatolHome page
E. Losina, R. P. Walensky, A. Geller, F. C. Beddingfield III, L. L. Wolf, B. A. Gilchrest, and K. A. Freedberg
Visual Screening for Malignant Melanoma: A Cost-effectiveness Analysis
Arch Dermatol, January 1, 2007; 143(1): 21 - 28.
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 Arch DermatolHome page
S. M. Swetter, S. Soon, C. R. Harrington, and S. C. Chen
Effect of Health Care Delivery Models on Melanoma Thickness and Stage in a University-Based Referral Center: An Observational Pilot Study
Arch Dermatol, January 1, 2007; 143(1): 30 - 36.
[Abstract] [Full Text] [PDF]

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M. Pashenkov, G. Goess, C. Wagner, M. Hormann, T. Jandl, A. Moser, C. M. Britten, J. Smolle, S. Koller, C. Mauch, et al.
Phase II Trial of a Toll-Like Receptor 9-Activating Oligonucleotide in Patients With Metastatic Melanoma
J. Clin. Oncol., December 20, 2006; 24(36): 5716 - 5724.
[Abstract] [Full Text] [PDF]

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 Cancer Epidemiol. Biomarkers Prev.Home page
C. Li, Z. Hu, Z. Liu, L.-E Wang, S. S. Strom, J. E. Gershenwald, J. E. Lee, M. I. Ross, P. F. Mansfield, J. N. Cormier, et al.
Polymorphisms in the DNA Repair Genes XPC, XPD, and XPG and Risk of Cutaneous Melanoma: a Case-Control Analysis
Cancer Epidemiol. Biomarkers Prev., December 1, 2006; 15(12): 2526 - 2532.
[Abstract] [Full Text] [PDF]

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 Cancer Res.Home page
D. Becker, M. C. Mihm, S. M. Hewitt, V. K. Sondak, J. W. Fountain, and M. Thurin
Markers and Tissue Resources for Melanoma: Meeting Report.
Cancer Res., November 15, 2006; 66(22): 10652 - 10657.
[Abstract] [Full Text] [PDF]

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 JCOHome page
T. A. Aloia and P. F. Mansfield
In Reply
J. Clin. Oncol., November 10, 2006; 24(32): 5178 - 5178.
[Full Text] [PDF]

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J. Rangel, S. Torabian, L. Shaikh, M. Nosrati, F. L. Baehner, C. Haqq, S. P.L. Leong, J. R. Miller III, R. W. Sagebiel, and M. Kashani-Sabet
Prognostic Significance of Nuclear Receptor Coactivator-3 Overexpression in Primary Cutaneous Melanoma
J. Clin. Oncol., October 1, 2006; 24(28): 4565 - 4569.
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 NEJMHome page
D. L. Morton, J. F. Thompson, A. J. Cochran, N. Mozzillo, R. Elashoff, R. Essner, O. E. Nieweg, D. F. Roses, H. J. Hoekstra, C. P. Karakousis, et al.
Sentinel-node biopsy or nodal observation in melanoma.
N. Engl. J. Med., September 28, 2006; 355(13): 1307 - 1317.
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S. Ugurel, D. Schadendorf, C. Pfohler, K. Neuber, A. Thoelke, J. Ulrich, A. Hauschild, K. Spieth, M. Kaatz, W. Rittgen, et al.
In vitro Drug Sensitivity Predicts Response and Survival after Individualized Sensitivity-Directed Chemotherapy in Metastatic Melanoma: A Multicenter Phase II Trial of the Dermatologic Cooperative Oncology Group.
Clin. Cancer Res., September 15, 2006; 12(18): 5454 - 5463.
[Abstract] [Full Text] [PDF]

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 Cancer Res.Home page
K. Gao, D. L. Dai, M. Martinka, and G. Li
Prognostic Significance of Nuclear Factor-{kappa}B p105/p50 in Human Melanoma and Its Role in Cell Migration.
Cancer Res., September 1, 2006; 66(17): 8382 - 8388.
[Abstract] [Full Text] [PDF]

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 CarcinogenesisHome page
C. Li, Z. Liu, L.-E Wang, S. S. Strom, J. E. Lee, J. E. Gershenwald, M. I. Ross, P. F. Mansfield, J. N. Cormier, V. G. Prieto, et al.
Genetic variants of the ADPRT, XRCC1 and APE1 genes and risk of cutaneous melanoma
Carcinogenesis, September 1, 2006; 27(9): 1894 - 1901.
[Abstract] [Full Text] [PDF]

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 Clin. Cancer Res.Home page
J. A. Campillo, J. A. Martinez-Escribano, M. R. Moya-Quiles, L. A. Marin, M. Muro, N. Guerra, A. Parrado, M. Campos, J. F. Frias, A. Minguela, et al.
Natural Killer Receptors on CD8 T Cells and Natural Killer Cells from Different HLA-C Phenotypes in Melanoma Patients.
Clin. Cancer Res., August 15, 2006; 12(16): 4822 - 4831.
[Abstract] [Full Text] [PDF]


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