Review 393
Evidence and interdisciplinary consense-based German
guidelines: diagnosis and surveillance of melanoma
Claus Garbea, Axel Hauschildb, Matthias Volkenandtc, Dirk Schadendorfd,
Wilhelm Stolzi, Uwe Reinholdj, Rolf-Dieter Kortmannk, Christoph Kettelhacko,
Bernhard Frerichl, Ulrich Keilholzm, Reinhard Dummerp, Günther Sebastiane,
Wolfgang Tilgenf, Gerold Schulerg, Andreas Mackensenn and
Roland Kaufmannh
Melanoma is a malignant tumor that arises from
melanocytic cells and primarily involves the skin. The most
important exogenous etiological factor is exposure to
ultraviolet irradiation. Diagnosis of melanoma is based
primarily on its clinical features, and the A–B–C–D rule is
useful in identifying pigmented lesions, which are
suspicious for melanoma (Asymmetry, Border irregular,
Color inhomogeneous and Diameter more than 5 mm).
Dermoscopy is very helpful in clarifying the differential
diagnosis of pigmented lesions. About 90% of melanomas
are diagnosed as primary tumors without any evidence for
metastasis. The tumor-specific 10-year survival for all such
c 2007 Wolters
tumors is about 75–85%. The most important prognostic
factors for primary melanoma without metastases are
vertical tumor thickness (Breslow depth) as measured on
the histological specimen, presence of histopathologically
recognized ulceration, invasion level (Clark level) and
identification of micrometastases in the regional lymph
nodes via sentinel lymph node biopsy. The current tumor
node metastasis classification for the staging of primary
melanoma is based on these factors. Melanomas
can metastasize either by the lymphatic or by the
hematogenous route. About two-thirds of metastases are
originally confined to the drainage area of regional lymph
nodes. A regional metastasis can appear as satellite
metastases up to 2 cm from the primary tumor, as intransit
metastases in the skin between the site of the primary
tumor and the first lymph node and as regional lymph
node metastases. In the stage of regional metastasis,
the differentiation between micrometastasis and
macrometastasis and the number of lymph nodes involved
are crucial. As soon as distant metastasis develops,
prognosis depends on the site of the metastasis and on
Purpose
The following guidelines have been written under the
auspices of the German Cancer Society and its working
groups and the German Dermatologic Society, to help
clinicians in diagnosing melanoma patients and managing
their surveillance. The report hopes to assist caregivers in
improving the management of melanoma patients. The
guidelines are also intended to promote the integration of
0960-8931
c 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the lactate dehydrogenase levels in the blood. The
frequency and extent of follow-up examinations is based
on the initial tumor parameters. In thin primary melanomas
up to 1-mm tumor thickness, clinical examinations at
6-month intervals are sufficient and in thicker primary
melanomas, at 3-month intervals. Lymph node sonography
as well as determination of the tumor marker protein
S100b are recommended. Additionally, in the stage of
regional metastasis, whole body imaging should be
performed every 6 months; in the stage of distant
metastasis, surveillance has to be scheduled
individually. Melanoma Res 17:393–399
Kluwer Health | Lippincott Williams & Wilkins.
Melanoma Research 2007, 17:393–399
Keywords: A–B–C–D rule, dermoscopy, melanoma diagnosis, surveillance,
tumor node metastasis classification
a
University Department of Dermatology, Tübingen, bUniversity Department of
Dermatology, Kiel, cUniversity Department of Dermatology, München, dUniversity
Department of Dermatology, Mannheim, eUniversity Department of Dermatology,
Dresden, fUniversity Department of Dermatology, Homburg, gUniversity
Department of Dermatology, Erlangen, hUniversity Department of Dermatology,
Frankfurt, iDepartment of Dermatology, München Schwabing, jDivision of
Dermatology, Medical Center Bonn Friedensplatz, Bonn, kUniversity Department
of Radiotherapy, lUniversity Department of Maxillo-Facial Surgery, Leipzig,
m
University Department of Medical Oncology, Charité Berlin, nUniversity
Department of Medical Oncology, Regensburg, Germany, oUniversity Department
of Surgery, Basel, Switzerland and pUniversity Department of Dermatology,
Zürich, Switzerland
Correspondence to Professor Claus Garbe, MD, Head of the Division of
Dermatooncology, Department of Dermatology, University Medical Center,
Liebermeisterstr. 25, Tübingen 72074, Germany
Tel: + 49 7071 298 7110; fax: + 49 7071 29 5187;
e-mail: claus.garbe@med.uni-tuebingen.de
Received 3 July 2007 Accepted 15 July 2007
care between medical and paramedical specialties for the
benefit of the patient.
The guidelines reflect the best published data available
at the time the report was prepared. Caution should be
exercised in interpreting the data; the results of future
studies might require the alteration of the conclusions or
the recommendations of this report. It might become
 394 Melanoma Research 2007, Vol 17 No 6
necessary or even desirable to depart from the guidelines
in the interests of specific patients and special circum-
stances. Just as adherence to the guidelines cannot
constitute a defence against a claim of negligence, so also
deviation from them should not necessarily be deemed as
negligence.
The evidence cited in the guidelines has been classified
as accurately as possible into five levels according to the
proposal of the Canadian Medical Association: level I
evidence is based on randomized, controlled trials (or the
meta-analysis of such trials) of adequate size, to ensure a
low risk of incorporating either false-positive or false-
negative results; level II on randomized, controlled trials
that are too small to provide level I evidence. These might
show either positive trends that are not statistically
significant or no trends, and are associated with a high risk
of false-negative results. Level III evidence is based on
nonrandomized, controlled or cohort studies, case series,
case–control studies or cross-sectional studies; level IV on
the opinion of respected authorities or that of expert
committees as indicated in published consensus confer-
ences or guidelines and level V expresses the opinion of the
individuals who have written and reviewed these guide-
lines, on the basis of their experience, knowledge of the
relevant literature and discussions with their peers. These
five levels of evidence do not directly describe the quality
or credibility of the evidence. Rather, they indicate the
nature of the evidence being used. In general, a
randomized, controlled trial has the greatest credibility
(level I); however, it might have defects that diminish its
value, and these should be noted. Evidence that is based on
too few observations to give a statistically significant result
is classified as level II. In general, level III studies carry less
credibility than level II or level I studies. The credibility of
level III studies is, nevertheless, increased when consistent
results are obtained from several such studies carried out
at different times and in different places.
Definition
Malignant melanoma is a malignant tumor that arises
from melanocytic cells and primarily involves the skin. In
the remaining part of these guidelines, the terms
malignant melanoma and melanoma will be used inter-
changeably, because there are no benign melanomas.
Melanomas can also arise in the eye (conjunctiva and
uvea), meninges and on various mucosal surfaces.
Although melanomas are usually heavily pigmented, there
are also amelanotic tumors. Even small tumors have a
tendency towards metastasis and thus have a relatively
unfavorable prognosis. Melanomas account for 90% of the
deaths associated with cutaneous tumors.
Epidemiology and etiology
The incidence of melanoma is increasing worldwide in
white populations, especially in places where fair-skinned
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
people receive excessive sun exposure [1,2]. In central
Europe, the incidence is 10–12/100 000/year; in the
United States, 10–25/100 000/year and in Australia, the
highest, 50–60/100 000/year. In individuals with more
pigmentation (Asians and Africans), melanomas are
uncommon and are almost always found on either the
acral or the mucosal surfaces [3]. Individuals with large
numbers of melanocytic nevi and those with congenital
nevi or multiple atypical nevi (dysplastic nevi) are at
greater risk [4–6]. The inheritance of melanoma is
polygenic: 5–10% of melanomas appear in melanoma-
prone families [7]. In addition to these genetic and
constitutional factors, the most important exogenous
factor is exposure to ultraviolet irradiation [8]. The
relative roles of toxic substances, medications and
hormones (pregnancy and oral contraceptives) are con-
troversial. The immune status of the patient plays a major
role in determining the course of the melanoma, as
numerous examples of spontaneous regression or of rapid
progression in immunosuppressed individuals demon-
strate.
Clinical features and histology
A number of different types of melanomas can be
identified clinically and histologically (Table 1). Some
tumors either represent mixed forms or are not classifi-
able. Examples of special forms are amelanotic melano-
mas, mucosal melanomas and other extracutaneous
melanomas, which together account for about 5% of all
melanomas.
Superficial spreading melanoma (SSM) starts with an
intraepidermal horizontal or radial growth phase, starting
as a macule and slowly evolving into a plaque, often with
multiple colors and pale areas of regression. Secondary
nodular areas might also develop. A characteristic
histological feature is the pagetoid spread of clear
malignant melanocytes throughout the epidermis.
Nodular melanoma, in contrast, is a primarily nodular,
exophytic brown-black, often eroded or bleeding tumor,
which has only a short horizontal growth phase and then
an aggressive vertical phase. Early identification in an
intraepidermal stage is thus almost impossible.
Table 1 Clinical-histological types of cutaneous melanoma in
German-speaking Europe
Type Abbreviation Percent Median age
(years)
Superficial spreading melanoma SSM 57.4 51
Nodular melanoma NM 21.4 56
Lentigo maligna melanoma LMM 8.8 68
Acral-lentiginous melanoma ALM 4.0 63
Unclassifiable melanoma UCM 3.5 54
Other 4.9 54
Results from the Central Malignant Melanoma Registry of the German
Dermatological Society 1983–1995 (n = 30.015).
 Guideline diagnosis and surveillance Garbe et al. 395

Lentigo maligna melanoma often arises after many years In 2001, the American Joint Committee on Cancer
from a lentigo maligna (melanoma in situ) almost proposed a new tumor node metastasis classification
exclusively on the faces of elderly individuals. Acral- and staging for melanoma; it has now also been accepted
lentiginous melanoma is usually palmoplantar, or sub- by the International Union Against Cancer [13,14]. This
ungual or periungual. In its early intraepidermal phase, new system now forms the cornerstone for classifying
there is irregular, poorly circumscribed pigmentation; melanomas and is summarized in Tables 2–5.
later a nodular region signals the invasive growth pattern.
Clinical and dermoscopic diagnosis
Prognosis and staging The A–B–C–D rule is useful in identifying pigmented
About 90% of melanomas are diagnosed as primary tumors lesions, which are suspicious for melanoma and worthy of
without any evidence for metastasis. The tumor-specific further investigation (level of evidence IV) [15,16].
10-year survival for all such tumors is around 75–80%.
The most important prognostic factors for primary 1. A = asymmetry
melanoma without metastases as reflected in recent 2. B = border irregular
studies are [9–11] as given below: 3. C = color inhomogeneous
4. D = diameter > 5 mm
1. vertical tumor thickness (Breslow depth), as measured
on a histological specimen with an optical micrometer: Dermoscopy is very helpful in clarifying the differential
vertical tumor thickness r 1.0 mm: 88–95% tumor- diagnosis of pigmented lesions (level of evidence III).
specific 10-year survival; 1.01–2.0 mm: 79–84% 10-year A meta-analysis of 22 studies involving 9004 pigmented
survival; 2.01–4.0 mm: 64–73% 10-year survival and
> 4.0 mm: 52–54% 10-year survival, all values being Table 2 T-classification of primary tumor for melanoma [14]
applicable for tumors without ulceration; T-classification Tumor thickness Additional prognostic parameters
2. presence of histologically recognized ulceration (mm)
(moves patient in the new American Joint Tis Melanoma in situ, no tumor invasion
Committee on Cancer classification to the next Tx No information Stage cannot be determineda
higher stage, see below); T1 r 1.0 (a) No ulceration, level II–III
(b) Ulceration or level IV–V
3. invasion level (Clark level) (especially helpful when T2 1.01–2.0 (a) No ulceration
distinguishing between level II/III and IV/V); (b) Ulceration
T3 2.01–4.0 (a) No ulceration
4. identification of micrometastases in the regional (b) Ulceration
lymph nodes via sentinel lymph node biopsy; T4 > 4.0 (a) No ulceration
5. sex (significantly worse prognosis in men) [9]; (b) Ulceration
6. tumor location (worse prognosis for upper trunk, upper a
Tumor thickness or information on ulceration not available or unknown primary
arms, neck and scalp) [12]. tumor.

Table 3 N-classifications of the regional lymph nodes for

Melanomas can metastasize either by the lymphatic or by melanoma [14]
the hematogenous route. About two-thirds of metastases are
N-classification Number of Extent of lymph node metastases
originally confined to the drainage area of the regional lymph involved lymph
nodes. A regional metastasis can appear in these forms: nodes (LN)

N1 1 LN (a) Micrometastases
(b) Macrometastases
1. satellite metastases (up to 2 cm from the primary N2 2–3 LN (a) Micrometastases
tumor), as well as local recurrence following the (b) Macrometastases
removal of the primary tumor with an inadequate (c) Satellite or intransit metastases
N3 Z 4 LN, satellite
excision margin; or intransit
2. intransit metastases (in the skin between the site of metastases with
node involvement
the primary tumor and the first lymph node);
3. regional lymph node metastases.

Table 4 M-classifications of distant metastases for melanoma [14]

The 10-year survival is 30–50% for patients with satellite
M-classification Type of distant metastasis Lactate
and in-transit metastases and 20–40% for those with dehydrogenase
regional lymph node metastases. Distant metastases have
M1a Skin, subcutaneous tissue or Normal
a grim prognosis with the median survival in untreated lymph node
patients only being 6–9 months, although there is M1b Lungs Normal
considerable variation depending on which of the internal M1c All other distant metastases or Normal elevated
any distant metastasis
organs are affected.

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 396 Melanoma Research 2007, Vol 17 No 6

Table 5 Staging of melanoma [14]

Stage Primary tumor (pT) Regional lymph node metastases (N) Distant metastases (M)

0 In-situ tumor None None

IA r 1.0 mm, no ulceration None None
IB r 1.0 mm with ulceration or Clark level IV or V None None
1.01–2.0 mm, no ulceration None None
IIA 1.01–2.0 mm with ulceration None None
2.01–4.0 mm, no ulceration None None
IIB 2.01–4.0 mm with ulceration None None
> 4.0 mm, no ulceration None None
IIC > 4.0 mm with ulceration None None
IIIA Any tumor thickness, no ulceration Micrometastases None
IIIB Any tumor thickness with ulceration Micrometastases None
Any tumor thickness, no ulceration Up to three macrometastases None
Any tumor thickness ± ulceration None but satellite and/or intransit metastases None
IIIC Any tumor thickness with ulceration Up to three macrometastases None
Any tumor thickness ± ulceration Four or more macrometastases, or lymph node involvement None
extending beyond capsule, or satellite and/or intransit
metastases with lymph node involvement
IV Distant metastases

skin lesions showed that when experts employed dermo- 3. level of invasion (Clark level);
scopy, they achieved a 35% increase in diagnostic accuracy 4. ulceration;
over the clinical diagnosis; thus they achieved a 5. regression;
sensitivity of 89% and a specificity of 79% [17]. Many 6. lymphatic, vascular or perineural involvement;
different dermoscopic scoring systems for the diagnosis of 7. microsatellites.
melanoma have been developed. Examples include
modified pattern analysis [18,19], A–B–C–D rule of
dermoscopy [20], Menzies’ scoring method [21] and When the histological diagnosis is unclear, or if an
the seven-point checklist [22]. All these methods lead to amelanotic melanoma or a metastatic melanoma is
an increased accuracy in diagnosing melanoma. Choosing suspected, immunohistochemical stains might be helpful
a method depends on one’s personal training and (S100 protein, HMB-45 antigen, Melan A and MIB-1 as
experience (level of evidence III). proliferation marker).

Follow-up examination with computer-assisted dermo- High-resolution sonography

scopy is also helpful (level of evidence III) [23]. Changes
in pigmented lesions can be more easily identified and
evaluated, examined at higher magnification and, in
addition, analyzed with digital image analysis programs.
Differential diagnosis involves identifying other pigmen-
ted melanocytic lesions (congenital, atypical and ordinary
melanocytic nevi and actinic lentigo) and excluding
nonmelanocytic pigmented lesions (seborrheic keratosis,
hemangioma and pigmented basal cell carcinoma). In
patients with an established melanoma, examination
remains essential to identify second primary tumors as
well as skin metastases.
Histopathological diagnosis
If a melanoma is suspected, histological examination is
mandatory. The diagnosis of melanoma is difficult not
only clinically but also under the microscope. The
specimen should be entrusted to a dermatopathologist
experienced in the interpretation of pigmented lesions.
The histopathological report should include the following
information:
1. type of melanoma;
2. tumor thickness in mm (Breslow depth);
High-resolution sonography can measure the tumor
thickness, facilitating the planning of excision margins
or decisions regarding the appropriateness of sentinel
lymph node biopsy (level of evidence III) [24]. If there is
an intense inflammatory infiltrate surrounding the tumor,
then its thickness will be overestimated. In addition,
sonography is more accurate in the case of thicker tumors
than in those less than 0.76 mm thick [25].
Further studies
The value of additional studies in patients with primary
melanomas is controversial. We recommend the following
approach for melanomas more than 1 mm thick, realizing
that some might also wish to employ it for thinner lesions.
Testing should include chest radiograph and sonography
of the regional lymph nodes and of the abdomen,
including the pelvis and retroperitoneum. The advantage
of carrying out these procedures even in patients with
thin tumors is that abnormalities such as liver cysts can be
identified; later their appearance in a patient with a
recurrence will not raise the fear of liver metastases. In
higher-risk patients, other procedures such as computer-
ized axial tomography, MRI and serum protein S100b
levels might be indicated, depending on the clinical
findings.

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Principles of surveillance
The frequency and extent of follow-up examinations
depend on the initial tumor parameters, just as the
treatment does. The first 5 years after surgery are most
important, as 90% of all metastases occur during this time
period. In contrast, melanoma has a tendency towards
late metastases; hence, the total follow-up period should
extend for 10 years. Finally, patients who have had a
melanoma have an increased risk of a second melanoma;
this adds increased importance to regular reevaluation.
Follow-up of melanoma patients has the following goals:
1. confirming that the tumor has not recurred or
identifying disease progression at the earliest
possible stage;
2. looking for melanoma precursors and second
melanomas;
3. offering psychosocial support;
4. documenting the disease course;
5. administering and monitoring adjuvant therapy, where
appropriate.
Issues in the literature
The German Dermatologic Society in 1994 recom-
mended a follow-up, which included frequent and
numerous evaluations [26]. In recent years, the nature
of follow-up for melanoma, as well as for most other solid
tumors, has been critically reviewed. The crucial issue is
whether a detailed follow-up increases the survival of
patients with metastatic melanoma [27–29]. This point is
critical for tumors for which there are limited therapeutic
possibilities when they have metastasized. The use of
various imaging procedures has been especially criticized,
as most recurrences are identified either through self-
examination or through clinical examination by the
physician [30–32]. Another area of concern has been
the use of imaging procedures to search for disease spread
at the time of the primary disease, as the yield was very
low [33–35].
Recommendations for structured follow-up
More recent German studies have provided data on the
follow-up of melanoma patients, which have led to
modifications in the recommendations. A retrospective
Table 6 Recommendations for the follow-up of melanoma patients (intervals in months) [38]
Stage and tumor thickness Physical examination Physical examination
(years) 1–5 (years) 6–10
I, = < 1 mm 6 6–12
I + II, > 1 mm 3 6–12
IIIa 3 6
IV
a
Stage III includes all forms of local and regional metastasis. The new AJCC stage IIC ( > 4-mm tumor thickness and ulceration) should be followed as stage III, as the
prognosis is similar.
b
S100 protein is the only parameter suited for detecting recurrences.
c
Abdominal sonography and chest radiograph or computer tomography, MRI or PET.
d
Patients receiving adjuvant therapy should receive imaging studies every 6–12 months.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Guideline diagnosis and surveillance Garbe et al. 397
study was performed in the Department of Dermatology
in Mannheim, in which the course of 661 melanoma
patients was reviewed with regard to follow-up [36]. The
Central Malignant Melanoma Registry in Tübingen
performed a prospective study during 1996–1998 evalu-
ating the results of follow-up in 2000 patients [37]. Both
studies confirm that the extent of the evaluation can be
reduced in patients in the primary tumor stage, especially
when the tumor is less than 1 mm thick [38]. The new
recommendations for follow-up are presented in Table 6.
If special risk factors are present, they can be modified.
In Germany, patients who have been treated for a primary
cutaneous melanoma are eligible for psychosocial coun-
seling and a variety of rehabilitation measures. The goal
of such programs is to help the patients to learn to cope
with their tumors without the disruption of their personal
and professional lives. In addition, if the tumor or its
treatment has caused functional damage, this problem
can also be addressed during the rehabilitation process.
Consensus-building process and participants
The guidelines were prepared under the auspices of the
German Cancer Society and its working groups and the
German Dermatologic Society. In addition, the Working
Group of German Tumor Centers, the Medical Center for
Quality Assurance and the Working Group for Support for
Quality Assurance in Medicine were involved, as were all
the groups mentioned below. Professor Claus Garbe,
Tübingen, coordinated the activities of the various
groups, the selected experts and the final authors.
An expert consensus conference with 20 experts from
different medical specialties was held on 14–15 February
2003. Agreement was reached on all the essential
questions concerning these guidelines. The details of
the guidelines were refined after multiple exchanges of
the manuscript between the members of the expert
group. Approval was likewise obtained from other
scientific specialty groups, which were coordinated by
the Information Center for Standards in Oncology (ISTO,
German Cancer Society). Eight different working parties
of the German Cancer Society took part in this process.
The Association of Scientific Medical Societies in
Lymph node sonography Serum S100 protein levels Imaging studies (years)
(years) 1–5 (years) 1–5b 1–5c
None None None
6 3–6 Noned
3–6 3–6 6
Individual
 398 Melanoma Research 2007, Vol 17 No 6
Germany organized the process of approval with 11
different scientific medical societies. The final changes
were added to these guidelines in March 2006 and they
remain valid until February 2009.
Acknowledgements
The authors thank the following individuals for their
participation in the expert conference and in the
subsequent process of approval through manuscript
exchanges: Jürgen Becker, Würzburg; Jörg Böttjer, Mind-
en; Helmut Breuninger, Tübingen; Reinhard Dummer,
Zürich; Alexander Enk, Heidelberg; Claus Garbe, Tübin-
gen; Sylke Gellrich, Berlin; Axel Hauschild, Kiel; Roland
Kaufmann, Frankfurt; Ulrich Keilholz, Berlin; Christoph
Kettelhack, Basel; Hans Christian Korting, München;
Rolf-Dieter Kortmann, Leipzig; Ruthild Linse, Erfurt;
Andreas Mackensen, Regensburg; Cornelia Mauch, Köln;
Peter Mohr, Buxtehude; Dorothée Nashan, Freiburg; Rolf
Ostendorf, Möchengladbach; Uwe Reinhold, Bonn; Mi-
chael Reusch, Hamburg; Dirk Schadendorf, Mannheim;
Martin Schläger, Oldenburg; Helmut Schöfer, Frankfurt;
Gerold Schuler, Erlangen; Günther Sebastian, Dresden;
Rudolph Stadler, Minden; Wolfram Sterry, Berlin; Wil-
helm Stolz, München; Wolfgang Tilgen, Homburg; Uwe
Trefzer, Berlin; Selma Ugurel, Mannheim; Jens Ulrich,
Quedlinburg; Matthias Volkenandt, München and
Michael Weichenthal, Kiel.
References
1 Armstrong BK, Kricker A. Cutaneous melanoma. Cancer Surv 1994;
19–20:219–240.
2 Garbe C, Blum A. Epidemiology of cutaneous melanoma in Germany and
worldwide. Skin Pharmacol Appl Skin Physiol 2001; 14:280–290.
3 Garbe C. Epidemiology of skin cancer [in German]. In: Garbe C, Dummer R,
Kaufmann R, Tilgen W, editors. Dermatologische Onkologie. Berlin,
Heidelberg, New York, Tokyo: Springer; 1997. pp. 40–56.
4 Garbe C, Buttner P, Weiss J, Soyer HP, Stocker U, Kruger S, et al. Risk
factors for developing cutaneous melanoma and criteria for identifying
persons at risk: multicenter case-control study of the Central Malignant
Melanoma Registry of the German Dermatological Society. J Invest
Dermatol 1994; 102:695–699.
5 Holly EA, Kelly JW, Shpall SN, Chiu SH. Number of melanocytic nevi as a
major risk factor for malignant melanoma. J Am Acad Dermatol 1987;
17:459–468.
6 MacKie RM, Freudenberger T, Aitchison TC. Personal risk-factor chart for
cutaneous melanoma. Lancet 1989; 2:487–490.
7 Greene MH, Clark W, Tucker MA, Kraemer KH, Elder DE, Fraser MC. High
risk of malignant melanoma in melanoma-prone families with dysplastic nevi.
Ann Intern Med 1985; 102:458–465.
8 Wiecker TS, Luther H, Buettner P, Bauer J, Garbe C. Moderate sun exposure
and nevus counts in parents are associated with development of
melanocytic nevi in childhood: a risk factor study in 1812 kindergarten
children. Cancer 2003; 97:628–638.
9 Garbe C, Buttner P, Bertz J, Burg G, d’Hoedt B, Drepper H, et al.
Primary cutaneous melanoma. Identification of prognostic groups and
estimation of individual prognosis for 5093 patients. Cancer 1995;
75:2484–2491.
10 Balch CM, Soong SJ, Gershenwald JE, Thompson JF, Reintgen DS,
Cascinelli N, et al. Prognostic factors analysis of 17 600 melanoma patients:
validation of the American Joint Committee on Cancer melanoma staging
system. J Clin Oncol 2001; 19:3622–2634.
11 Garbe C, Ellwanger U, Tronnier M, Brocker EB, Orfanos CE. The New
American Joint Committee on Cancer staging system for cutaneous
melanoma: a critical analysis based on data of the German Central
Malignant Melanoma Registry. Cancer 2002; 94:2305–2307.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
12 Garbe C, Büttner P, Bertz J, Burg G, d’Hoedt B, Drepper H, et al.
Primary cutaneous melanoma: prognostic classification of anatomic location.
Cancer 1995; 75:2492–2498.
13 Balch CM, Buzaid AC, Atkins MB, Cascinelli N, Coit DG, Fleming ID, et al.
A new American Joint Committee on Cancer staging system for cutaneous
melanoma. Cancer 2000; 88:1484–1491.
14 Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Coit DG, et al.
Final version of the American Joint Committee on Cancer staging system for
cutaneous melanoma. J Clin Oncol 2001; 19:3635–3648.
15 Garbe C. Initial diagnostics, staging diagnostics and estimation of
prognosis in primary melanoma [in German]. Onkologe 1996; 2:
441–448.
16 Kaufmann R, Proebstle T, Sterry W. Malignant melanoma [in German].
In: Zeller WJ, zur Hausen H, editors. Onkologie. Erlangen: Ecomed; 1995.
17 Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of
dermoscopy. Lancet Oncol 2002; 3:159–165.
18 Pehamberger H, Binder M, Steiner A, Wolff K. In vivo epiluminescence
microscopy: improvement of early diagnosis of melanoma. J Invest Dermatol
1993; 100:356S–362S.
19 Soyer H, Argenziano G, Chimenti S, Menzies SW, Pehamberger H,
Rabinowitz HS, et al. Dermoscopy of pigmented skin lesions. An atlas
based on the Consensus Net Meeting on Dermoscopy 2000. Milan:
Edra; 2001.
20 Stolz W, Riemann A, Cognetta AB, Pillet L, Abmayr W, Hölzel D, et al. ABCD
rule of dermoscopy: a new practical method for early recognition of
malignant melanoma. Eur J Dermatol 1994; 4:521–527
21 Menzies SW, Ingvar C, McCarthy WH. A sensitivity and specificity analysis
of the surface microscopy features of invasive melanoma. Melanoma Res
1996; 6:55–62.
22 Argenziano G, Fabbrocini G, Carli P, de Giorgi V, Sammarco E, Delfino M.
Epiluminescence microscopy for the diagnosis of doubtful melanocytic
skin lesions. Comparison of the ABCD rule of dermatoscopy and a new
7-point checklist based on pattern analysis. Arch Dermatol 1998; 134:
1563–1570.
23 Kittler H, Pehamberger H, Wolff K, Binder M. Follow-up of melanocytic skin
lesions with digital epiluminescence microscopy: patterns of modifications
observed in early melanoma, atypical nevi, and common nevi. J Am Acad
Dermatol 2000; 43:467–476.
24 Krahn G, Gottlober P, Sander C, Peter RU. Dermatoscopy and high
frequency sonography: two useful non-invasive methods to increase
preoperative diagnostic accuracy in pigmented skin lesions. Pigment Cell
Res 1998; 11:151–154.
25 Serrone L, Solivetti FM, Thorel MF, Eibenschutz L, Donati P, Catricala C.
High frequency ultrasound in the preoperative staging of primary melanoma:
a statistical analysis. Melanoma Res 2002; 12:287–290.
26 Orfanos CE, Jung EG, Rassner G, Wolff HH, Garbe C. Position and
recommendations of the Malignant Melanoma Committee of the German
Society of Dermatology on diagnosis, treatment and after-care of malignant
melanoma of the skin. Status 1993/94 [in German]. Hautarzt 1994;
45:285–291.
27 Eggermont AM. Monitoring of patients with stage I melanoma after excision
of the primary tumor [in French]. Ann Dermatol Venereol 1995; 122:
292–297.
28 Eggermont AM. Monitoring of patients with stage I melanoma after excision
of the primary tumor: simple and cost efficient [in German]. Der Onkologe
1996; 2:480.
29 Kleeberg UR. Wishful thinking, unicentric empiricism and the everyday
world of the medical melanomologist. Melanoma Res 1997; 7 (Suppl 2):
S143–S149.
30 Ardizzoni A, Grimaldi A, Repetto L, Bruzzone M, Sertoli MR, Rosso R.
Stage I-II melanoma: the value of metastatic work-up. Oncology 1987;
44:87–89.
31 Basseres N, Grob JJ, Richard MA, Thirion X, Zarour H, Noe C, et al. Cost-
effectiveness of surveillance of stage I melanoma. A retrospective appraisal
based on a 10-year experience in a dermatology department in France.
Dermatology 1995; 191:199–120.
32 Weiss M, Loprinzi CL, Creagan ET, Dalton RJ, Novotny P, O’Fallon JR. Utility
of follow-up tests for detecting recurrent disease in patients with malignant
melanomas. JAMA 1995; 274:1703–1705.
33 Huang CL, Provost N, Marghoob AA, Kopf AW, Levin L, Bart RS. Laboratory
tests and imaging studies in patients with cutaneous malignant melanoma.
J Am Acad Dermatol 1998; 39:451–463.
34 Iscoe N, Kersey P, Gapski J, Osoba D, From L, DeBoer G, Quirt I. Predictive
value of staging investigations in patients with clinical stage I malignant
melanoma. Plast Reconstr Surg 1987; 80:233–239.
 Guideline diagnosis and surveillance Garbe et al. 399

35 Terhune MH, Swanson N, Johnson TM. Use of chest radiography in the initial
evaluation of patients with localized melanoma. Arch Dermatol 1998;
134:569–572.
36 Hofmann U, Szedlak M, Rittgen W, Jung EG, Schadendorf D. Primary
staging and follow-up in melanoma patients: monocenter evaluation
of methods, costs and patient survival. Br J Cancer 2002; 87:
151–157.
37 Garbe C, Paul A, Kohler-Spath H, Ellwanger U, Stroebel W, Schwarz M,
et al. Prospective evaluation of a follow-up schedule in cutaneous melanoma
patients: recommendations for an effective follow-up strategy. J Clin Oncol
2003; 21:520–529.
38 Garbe C, Schadendorf D. Malignant melanoma: new data and concepts
of surveillance [in German]. Dtsch Arztebl 2003; 100.A:
1804–1808.

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