黑色素瘤分期.ppt

1、黑色素瘤分期,HISTORICAL ASPECTS OF MELANOMA STAGING,Allen and Spitz in their classic paper published in 1953, were the first to report that deeper melanomas had a worse prognosis than more superficial melanomas. However, they did not propose a formal staging system based on this observation.,One of the fi

2、rst attempts to classify melanoma patients according to the severity of their disease was that of Ackerman and Del Regato in 1954 .,four subgroups:,patients with distant metastases patients with regional lymph node metastases clinically detected and histologically proven patients with clinically neg

3、ative but histologically positive regional lymph nodes patients with primary disease only, as demonstrated by the clinical and histologic absence of disease either in regional lymph nodes or at distant sites.,By 1964, clear differences in survival had been demonstrated in three groups of patients on

4、 the basis of clinical assessmentthose with primary disease only, those with regional lymph node metastases, and those with distant disease. Recognition of these categories led to the establishment of a three-stage system by McNeer and Das Gupta from the Memorial Sloan-Kettering Cancer Center.,The M

5、cNeer and Das Gupta Three Stage System,In 1969, Clark et al. refined the earlier work of Petersen et al. and Mehnert and Heard by identifying five prognostic categories known now as Clark levels of invasion. The Clark microstaging is based on the depth of infiltration of the melanoma into the skin.,

6、level I, which means in situ melanoma, not infiltrating through the basal cell layer; level II, infiltration into the papillary dermis; level III, infiltration as far as, but not into the reticular dermis; level IV, infiltration into the reticular dermis; level V, infiltration into the subcutaneous

7、tissue.,1970, Breslow demonstrated that tumor thickness was an important prognostic variable . This factor was later established in 1978 to be prognostically more powerful than Clark level of invasion both by Breslow himself and by Balch et al. .,In 1978, the AJCC and the Union Internationale Contre

8、 le Cancer (UICC) incorporated primary melanoma microstaging into their staging systems. They used both Clark level of invasion and tumor thickness in an effort to stage melanoma patients more accurately, but these stages still consigned too many patients to Stage I to make it a useful system.,The 1

9、978 AJCC Staging System,The 1978 UICC Staging System,The 1988 AJCC/UICC Staging System,The Staging Committee considered all the information that was available in the literature, assembled a 17,600 patient database, of the AJCC Staging Manual that was published in 2002 .,AJCC new staging system,Prima

10、ry tumour,T1 tumour0/1.0 mm thick A: without ulceration and Clarks level II/III B: with ulceration or Clarks level IV/V T2 tumour 1.01_/2.0 mm thick A: without ulceration B: with ulceration T3 tumour 2.01_/4.00 mm thick A: without ulceration B: with ulceration T4 tumour_/4.00 mm thick A: without ulc

11、eration B: with ulceration,Regional lymph nodes,N1 1 node A: micrometastasis B: macrometastasis N2 2_/3 nodes A: micrometastasis B: macrometastasis C: in-transit metastases/satellite(s) without metastatic nodes N3 4 or more metastatic nodes or matted nodes or in-transit metastases satellite(s) with

12、metastatic nodes,Distant metastasis,M1a distant skin, subcutaneous or nodal metastases LDH Normal M1b lung metastases LDH Normal M1c visceral metastases. Any distant metastases LDH Elevated,Stages Clinical staging,0 Tis N0 M0 IA T1a N0 M0 IB T1b N0 M0 T2a N0 M0 IIA T2b N0 M0 T3a N0 M0 IIB T3b N0 M0 T4a N0 M0 IIC T4b N0 M0 III Any T N1 M0 N2 N3 IIIA T1-4a N1-2a M0 IIIB T1-4b N1-2a M0 T1-4a N1-2b M0 T1-4a/b N2c M0 IIIC T1-4b N1-2b M0 T1-4b N2b M0 Any T N3 M0 IV Any T, any N, M1,Changes in melanoma staging comparing previous (1997) and new (2002) vers