Breslow's depth

In medicine, Breslow's depth was used as a prognostic factor in melanoma of the skin. It is a description of how deeply tumor cells have invaded. Currently, the standard Breslow's depth has been replaced by the AJCC depth, in the AJCC staging system of melanoma. Originally, Breslow's depth was divided into 5 stages.[1]

Classification

Breslow's depth
StageDepth
Stage I0.75mm or less
Stage II0.76 mm - 1.50mm
Stage III1.51mm - 4.00 mm
Stage IV>4mm

History

Depth of invasion was first reported as a prognostic factor in melanoma by the pathologist Alexander Breslow, M.D. at George Washington University in 1970.[1] In recognition of his contribution, the depth of invasion of melanoma is referred to by the eponym Breslow's depth.

Subsequent studies confirmed and refined the role of depth of invasion in the prognosis of malignant melanoma.[2][3] Currently, Breslow's depth is included in the AJCC staging guidelines for melanoma as a major prognostic factor.

Measurement

Tumor depth is most accurately measured by evaluating the entire tumor via an excisional biopsy. Determination from specimens obtained using other biopsy techniques, such as a wedge or punch biopsy, are less accurate. Tumor depth cannot be calculated from a shave biopsy that only contains a portion of the tumor because it leads to an underestimation of its thickness.

Breslow's depth is determined by using an ocular micrometer at a right angle to the skin to directly measure the depth to which tumor cells have invaded the skin. Breslow's depth is measured from the granular layer of the epidermis down to the deepest point of invasion (sometimes involving detached nests of cells).

Prognostic importance

Tumor depth is one of the cornerstones of the current AJCC TNM staging of malignant melanoma. A large study validated the importance of tumor depth (but not Breslow's original description) as one of the three most important prognostic factors in melanoma (the others being T stage and ulceration).[4] Breslow's depth also accurately predicted the risk for lymph node metastasis, with deeper tumors being more likely to involve the nodes.[5]

The above studies showed that depth was a continuous variable correlating with prognosis. However, for staging purposes, the most recent AJCC guidelines use cutoffs of 1 mm, 2 mm, and 4 mm to divide patients into stages.

Tumor Depth Approximate 5 year survival
< 1 mm 95–100%
1–2 mm 80–96%
2.1–4 mm 60–75%
> 4 mm 50%

Survival figures from British Association of Dermatologist Guidelines, 2002

Clark's level

Clark's level is a related staging system, used in conjunction with Breslow's depth, which describes the level of anatomical invasion of the melanoma in the skin.[6] Clark's level was the primary factor in earlier AJCC staging schemas for melanoma. However, with further study, it has been shown that Clark's level has a lower predictive value, is less reproducible, and is more operator-dependent as compared with Breslow's depth. Thus, in the current (2010) AJCC staging system, Clark's level has prognostic significance only in patients with very thin (Breslow depth <1 mm) melanomas.[4]

Five anatomical levels are recognized, and higher levels have worsening prognostic implications. These levels are:

See also

References

  1. 1 2 Breslow, Alexander (1970). "Thickness, Cross-Sectional Areas and Depth of Invasion in the Prognosis of Cutaneous Melanoma". Annals of Surgery. 172 (5): 902–8. doi:10.1097/00000658-197011000-00017. PMC 1397358. PMID 5477666.
  2. ↑ Büttner, Petra; Garbe, Claus; Bertz, Jochen; Burg, Günter; d'Hoedt, Barbara; Drepper, Hubert; Guggenmoos-Holzmann, Irene; Lechner, Walter; et al. (1995). "Primary cutaneous melanoma. Optimized cutoff points of tumor thickness and importance of clark's level for prognostic classification". Cancer. 75 (10): 2499–2506. doi:10.1002/1097-0142(19950515)75:10<2499::AID-CNCR2820751016>3.0.CO;2-8. PMID 7736394.
  3. ↑ Buzaid, AC; Ross, MI; Balch, CM; Soong, S; McCarthy, WH; Tinoco, L; Mansfield, P; Lee, JE; et al. (1997). "Critical analysis of the current American Joint Committee on Cancer staging system for cutaneous melanoma and proposal of a new staging system". Journal of Clinical Oncology. 15 (3): 1039–51. PMID 9060544.
  4. 1 2 Balch, CM; Soong, SJ; Gershenwald, JE; Thompson, JF; Reintgen, DS; Cascinelli, N; Urist, M; McMasters, KM; et al. (2001). "Prognostic factors analysis of 17,600 melanoma patients: Validation of the American Joint Committee on Cancer melanoma staging system". Journal of Clinical Oncology. 19 (16): 3622–34. PMID 11504744.
  5. ↑ Rousseau, Dennis L.; Ross, Merrick I.; Johnson, Marcella M.; Prieto, Victor G.; Lee, Jeffrey E.; Mansfield, Paul F.; Gershenwald, Jeffrey E. (2003). "Revised American Joint Committee on Cancer Staging Criteria Accurately Predict Sentinel Lymph Node Positivity in Clinically Node-Negative Melanoma Patients". Annals of Surgical Oncology. 10 (5): 569–74. doi:10.1245/ASO.2003.09.016. PMID 12794025.
  6. 1 2 Weedon, D. Skin pathology. 2nd Edition. 2002. Sydney: Churchill-Livingstone. ISBN 0-443-07069-5
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