< Current issue
Dermatopathology: Practical & Conceptual July - September 2002
Flawed Concept: Staging of Melanoma: A Critique in Historical Perspective
Bradley Bakotic, D.O.
A. Bernard Ackerman, M.D.
Systems of Staging in Chronologic Sequence: L.V. Ackerman and Delgato (1947)
American Joint Committee on Cancer (1962–1965)
McNeer and Das Gupta (1964)
M.D. Anderson Cancer Center (1976)
American Joint Committee on Cancer (1977)
Union Internationale Contre Le Cancer (1978)
American Joint Committee on Cancer (1983)
American Joint Committee on Cancer and Union Internationale Contre le Cancer (1988, 1992, 1997)
American Joint Committee on Cancer (2000, 2001)
“Evolution” in Staging is Paralleled by Devolution in Critical Thought
"Evolution" in Staging is Paralleled by Devolution in Critical Thought
In the course of the evolution of staging of melanoma, criteria believed to be of utmost magnitude by some investigators were abandoned later by others, only to appear again subsequently. Some criteria, such as in-transit metastasis, have been given entirely different weight in different systems of staging. For instance, in the three-tier system of Sylven, patients with in-transit metastases were classified as Stage I, the best prognostic category, whereas in the system of the AJCC in 1983, persons with > 5 in-transit metastases were assigned to Stage IV, the worst prognostic group possible. Most recently, in its system for staging of 2001, the AJCC has placed such persons in Stage III which is intermediate in severity of prognosis. Perhaps the flaw inherent in staging of melanoma is the fact that, conceptually, there are just two stages: I—melanoma prior to metastasis and II—metastatic melanoma.
In sum and in short, there is no escape from the conclusion that systems for staging cancer, and melanoma in particular, have changed radically during the past 55 years. Moreover, criteria thought to be of quintessential consequence at the outset have been jettisoned now, and those that are considered to be of consummate importance today are likely to become as passé as those that rightly have been abandoned. In actuality, there are only two stages that matter to a patient, and, thereby, to a physician who bears responsibility for managing that patient, namely, a primary melanoma before it has metastasized (and, therefore, is curable by complete excision, no matter how narrow the margin
) and metastases from the primary melanoma (and, therefore, not curable by any means available currently). Other "stages" represent imaginary "breakpoints" that result from mystical thinking. In the ultimate analysis, all attempts to stage melanoma for the purpose of prognostication have been an exercise in futility. The job of a histopathologist is diagnosis, not prognosis.
The latter is the province of diviners, seers, and prophets. Pathologists would be well advised to concentrate their cerebral energies on forging criteria for diagnosis that work in difficult, challenging, vexing cases. That that has yet to be accomplished within the realm of melanocytic neoplasia is evident painfully.
Dr. Bakotic did this work in 2001 while a Fellow at the Ackerman Academy of Dermatopathology. He is now at the Department of Pathology at Sacred Heart Hospital, Pensacola, Florida. Dr. Ackerman is director of the Academy.
This site is made possible in part by:
Copyright © Derm101.com. All Rights Reserved.