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. | 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 1015 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 Stage Thickness mm Ulceration Nodal Disease Distant Metastases 0 In situ N A No No IA 1 No No No IB 1 Yes No No .
