Breslow Thickness & Melanoma Staging
Breslow thickness is the primary determinant of melanoma T-stage and sentinel lymph node biopsy eligibility. Based on AJCC 8th edition staging.
Score interpretation
Stage I (pT1a, pT1b or pT2a, N0 M0). 10-year melanoma-specific survival about 95% (AJCC 8th).
→ Wide local excision with a 1 cm clinical margin (NICE NG14). SLNB: not offered for stage IA (< 0.8 mm without ulceration); consider for 0.8–1.0 mm with ulceration, lymphovascular invasion or mitotic index ≥ 2, and for Breslow > 1.0 mm (NICE NG14 2022). Dermatology and/or plastic surgery referral. No adjuvant therapy routinely indicated for Stage I.
Stage II (pT2b–pT4b, N0 M0). 10-year melanoma-specific survival about 84% (88% IIA to 75% IIC; AJCC 8th).
→ WLE with a 2 cm clinical margin (NICE NG14). Consider SLNB (Breslow > 1.0 mm); if SLNB positive → Stage III management. Staging CT: consider for IIB, offer for IIC (NICE NG14). Consider adjuvant immunotherapy (pembrolizumab or nivolumab) for Stage IIB/IIC. MDT discussion. Oncology referral. 3–6-monthly surveillance.
Stage III: regional lymph node, in-transit, satellite or microsatellite metastases. 10-year melanoma-specific survival about 69% overall (AJCC 8th).
→ Therapeutic lymph node dissection for palpable or imaging-detected nodal disease; completion lymph node dissection is not routinely offered for micrometastases found at SLNB (NICE NG14 2022). Adjuvant therapy: anti-PD1 (pembrolizumab / nivolumab) or BRAF/MEK inhibitor (dabrafenib + trametinib) if BRAF V600 mutant. Molecular testing (BRAF). Staging CT. Clinical trial enrolment if available.
Stage IV: Distant metastases. Median OS now ~3 years with modern immunotherapy.
→ Molecular testing (BRAF/MEK). First-line: ipilimumab + nivolumab (high response rate, significant toxicity) or pembrolizumab monotherapy. BRAF-mutant: dabrafenib + trametinib. Brain metastases: stereotactic radiosurgery ± systemic therapy. Palliative care involvement. Clinical trial.
Interpretation bands for the Breslow / Melanoma. Apply clinical judgement and local guidance.
References
- Gershenwald JE, Scolyer RA, Hess KR, et al. Melanoma staging: evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(6):472–492.
- NICE NG14. Melanoma: assessment and management. 2015 (updated 2022).
Related
Curated clinical cross-links plus same-class fallbacks.
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- Suspicious Pigmented Lesion — Melanoma Pathway · NICE NG14 2015 / BAD
- Cellulitis and Erysipelas · NICE NG141 2019 / CREST
- Psoriasis — Severity Assessment and Step-Up Therapy · NICE NG153 2019 / BAD
- Atopic Eczema — Assessment and Step-Up Therapy · NICE NG95 2023
- Urticaria and Angioedema · BSACI / EAACI Guidelines 2022
- Acne Vulgaris — Grading and Treatment · NICE NG198 2021 / BAD
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.