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Evidence for Revisiting the Staging Classification

Glen M. Bowen, MD; Alfred E. Chang, MD; Lori Lowe, MD; Ted Hamilton, MS; Rupa Patel, BA; Timothy M. Johnson, MD

Arch Dermatol. 2000;136:1397-1399.

Background  Several patients presented with a single focus of presumed cutaneous metastatic melanoma with an unknown primary tumor based on clinical and histologic staging criteria of the American Joint Committee on Cancer (AJCC). This population is classified as having stage IV disease by the current AJCC staging system, which carries a dismal prognosis (5%-18% 5-year survival). Our clinical observation was that these patients had a higher survival rate than would be expected for stage IV disease. We believe this population represents a subgroup of primary dermal- and or subcutaneously-derived melanoma that simulates cutaneous metastatic melanoma in histologic and clinical presentation but may differ in behavior.

Observations  The database records of 1800 patients from the University of Michigan Melanoma Clinic, Ann Arbor, were retrospectively reviewed to identify the prevalence and survival for patients diagnosed with a single focus of presumed metastatic melanoma to the skin based on accepted histologic and clinical parameters. The prevalence of this population was 0.61% (11 of 1800 patients). The Kaplan-Meier 8-year survival estimate was 83% (95% confidence interval, 58%-100%).

Conclusions  By AJCC convention, these cases are classified as stage IV metastatic disease. Our data suggest that these presumed metastatic tumors do not behave like stage IV metastatic disease to the skin via lymphatic or hematogenous spread from an unknown primary site; rather, they are behaving like primary tumors originating in the dermal and/or subcutaneous tissue.

From the Department of Dermatology, University of Utah, Salt Lake City (Dr Bowen); and the Departments of Dermatology (Drs Lowe and Johnson, Mr Hamilton, and Ms Patel), Otorhinolaryngology (Dr Johnson), Surgery (Drs Chang and Johnson), and Pathology (Dr Lowe), University of Michigan Health System, and University of Michigan Comprehensive Cancer Center, Ann Arbor.

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