1Chairman, AJCC Melanoma Staging Committee, Departments of Surgery and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD; 2Member, AJCC Melanoma Staging Committee, Clinical Professor of Pathology, Harvard Medical School/Massachusetts General Hospital, Co Chairman, Pathology Committee, WHO Melanoma Program, USA
The EORTC Melanoma Group has written a thorough analysis of the proposed melanoma staging system published previously by the Melanoma Staging Committee of the American Joint Committee on Cancer (AJCC) [1]. The EORTC Melanoma Group leadership have also provided helpful input, some of which contributed to the final revisions of the staging criteria. To validate the accuracy of this proposed staging system, 13 cancer centers and cancer cooperative groups contributed staging and survival data from 17 600 melanoma patients from the United States, Europe and Australia [2]. This analysis, along with advice from melanoma experts, has resulted in a final version which has been formally approved by the AJCC as well as the International Union against Cancer (UICC) TNM Committee. This final version of the melanoma staging system will become official with publication of the 6th edition of the AJCC Cancer Staging Manual in the year 2002.
Specific responses to the suggestions and comments made by Dr Ruiter and colleagues include the following:
Most importantly, we agree with the EORTC Melanoma Group that it is vitally important to distinguish between preoperative clinical staging and postoperative pathological staging. Our own prognostic factors analysis and those from many other institutions have consistently demonstrated that the nodal status is a very significant prognostic feature of melanoma [2, 1618]. Significant differences were identified when survival rates for melanoma patients, who were clinically staged, were compared to those of the same T category whose nodal disease was staged pathologically. The differences were most striking in patients with clinical T2bN0M0, T3aN0M0, T3bN0M0 and T4aN0M0 disease, where 10-year survival rates for the same category of clinically versus pathologically staged patients varied significantly with diminished survival ranging from 20% to 29% (table 6). These results highlight the compelling prognostic value of knowing the nodal status as identified by lymphatic mapping and sentinel lymphadenectomy in those situations where accurate staging is important. The AJCC Melanoma Committee has strongly recommended that all patients with clinical T2N0M0, T3N0M0 and T4N0M0 melanomas have pathological nodal staging with sentinel lymphadenectomy prior to entry into melanoma clinical trials.
We thank the authors and the Annals of Oncology for the opportunity to respond to this article so promptly.
C. M. Balch & M. C. Mihm
Chairman, AJCC Melanoma Staging Committee, Departments of Surgery and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD; Member, AJCC Melanoma Staging Committee, Clinical Professor of Pathology, Harvard Medical School/Massachusetts General Hospital, Co Chairman, Pathology Committee, WHO Melanoma Program, USA
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