Even less than half a century ago, skin melanoma (see photo below) was quite rare. However, in recent decades, more and more people have come across this disease. According to medical statistics, the annual growth rate of this pathology is approaching five percent. That is why it is worth knowing what symptoms melanoma has, what kind of disease it is, how dangerous it is and how to get rid of it.
Description of pathology
One type of malignant skin disease is called melanoma. What is this pathology? This is a disease that develops from melanocytes, that is, special pigment cells that produce melanins. The pathology has an aggressive, often unpredictable and variable clinical course.
Most often, melanoma is found on the skin. Much less often, it affects the mucous membrane of the larynx, eyes, mouth and nose. Sometimes melanoma is found on the skin of the anus, external auditory canal, as well as on the female external genitalia.
If a person has melanoma, what does this mean? The presence of this neoplasm suggests that the patient is affected by one of the most severe types of cancer, which is in sixth place in terms of the incidence of malignant tumors in men and in second place in women. Most often, melanoma affects quite young people, whose age ranges from 15 to 40 years.
Sometimes melanoma develops on its own. However, most often the neoplasm is disguised as birthmarks. That is why the pathology at first does not cause any concern in people and is difficult to recognize with early diagnosis. This is another danger that melanoma carries. What is this danger? It lies in the fact that melanoma for a relatively short period (about a year) spreads in The lymph nodes, and through them metastases penetrate into almost all organs of the human body.
Reasons for the appearance
What causes melanoma? What can this neoplasm provoke? According to the modern theory of the appearance and further mechanism of development of melanomas, the causes of these tumors lie in molecular genetic factors.
In healthy cells, a gene mutation occurs that damages DNA. This leads to a change in the number of genes and to chromosomal rearrangements. Cells have a predisposition to unlimited reproduction, tumor growth and rapid metastasis. Such disorders provoke exogenous or endogenous risk factors. Sometimes the development of melanoma occurs due to their joint action.
Exogenous risk factors include:
- intense and prolonged exposure to the ultraviolet spectrum of solar radiation;
- increase in the background of ionizing radiation;
- electromagnetic radiation;
- mechanical injuries of birthmarks;
- exposure to a chemically aggressive environment;
- nutritional features;
- taking estrogenic drugs and oral contraceptives.
Endogenous risk factors include:
- low degree of skin pigmentation;
- hereditary predisposition;
- endocrine disorders;
- immunodeficiency;
- the presence of birthmarks (benign formations);
- period of pregnancy and lactation.
Symptoms
What does melanoma look like in the initial stages of its development? At this stage, it is not much different from a birthmark.
What does melanoma look like in this case (photo - initial stage - presented below)?
A malignant neoplasm may be a flat pigmented or non-pigmented spot, characterized by a slight elevation. At the same time, melanoma has an oval, irregular or rounded polygonal shape with a diameter of more than 6 mm. The initial stage of this pathology lasts a certain time. At the same time, the stain retains its shiny and smooth surface. But in the future, the appearance of this neoplasm becomes different from that which the mole has. Melanoma becomes a patch with small ulcerations and bumps. In addition, it bleeds even with the slightest injury. Pigmentation in this pathology is uneven. However, it has a more intense color in the central part of the spot. Below you can see what melanoma looks like (photo).
Symptoms, in addition to more intense pigmentation, are characteristic black rims located around the base. In general, melanoma can be black with blue, brown, purplish or variegated, looking like unevenly distributed individual spots. In some cases, the neoplasm looks like overgrown papillomas (see a photo of this type of melanoma below).
Sometimes the tumor takes the form of a fungus, which is on a stalk or on a wide base. In the immediate vicinity of melanoma, additional tumor foci sometimes appear. They are called satellites. These neoplasms are located separately or merge with the main tumor.
Sometimes melanomas are just a slight reddening. Further, it turns into a permanent ulcer, at the bottom of which growths appear. If melanoma develops against the background of a mole, then it can manifest itself on its periphery with the formation of an asymmetric formation.
When should you see a doctor?
There are some of the most reliable and significant symptoms that confirm the transition of a benign neoplasm to a malignant one. These signs are:
- rapid growth of a mole;
- changes in the outlines and shape of an already existing nevus;
- the disappearance of uniformity in the color of the birthmark;
- decrease or increase in pigmentation of formations;
- the appearance of itching, tingling, burning or a feeling of "bursting" of the mole;
- the disappearance of the hairline from the surface of the spot;
- the occurrence of cracks, bleeding, peeling even with light friction on clothing;
- growth of a mole like a papilloma.
If a person has at least one of these symptoms, then he should contact a medical institution that has an oncological focus. This will allow timely differential diagnosis and resolve the issue of melanoma treatment.
Stages of development
A malignant tumor goes through the following stages:
- initial, or local;
- I, when the spot has a thickness of 1 mm with ulceration or 2 mm without them (a photo of melanoma at this stage is presented below);
- II, in which neoplasms with a damaged surface have a diameter of up to 2 mm, and with a smooth surface - up to 4 mm;
- III - this is the stage, which is characterized by any size and thickness of a tumor that has nearby foci or metastases;
- IV, the last stage is characterized by the germination of the neoplasm in distant lymph nodes and in many organs.
If treatment is not carried out, then all the stages described above pass through melanoma. See photo of the neoplasm below.
Diagnostics
A doctor can make an accurate diagnosis of the presence of a malignant tumor based on the following:
- patient complaints about a suspicious mole and its visual examination;
- a general clinical analysis of urine and blood;
- the method of hardware dermatoscopy used, which allows you to examine the neoplasm in the skin layers and draw conclusions about its boundaries and nature;
- holding ultrasound abdominal cavity, chest radiography, magnetic resonance and computed tomography of the head and spinal cord, which allow you to determine the presence and spread of metastases in various organs;
- pathological examination of a smear or materials obtained as a result of a puncture;
- conducting an excisional biopsy, in which suspicious moles are excised, followed by a histological examination.
Pigmentless or achromatic melanoma
There are several various kinds melanoma. Their type depends on the nature of growth and cellular composition. Such a classification suggests that different forms of the tumor have a different tendency to spread.
Pigmentless melanoma is detected much less often than other types. It is difficult to diagnose, as it does not have a specific color. See photos of this type of melanoma below.
Such neoplasms are noticed quite late, when they are already at the very last stages of their development.
The formation of pigmentless melanoma begins with a compaction of small sizes. Further, the neoplasm increases and is covered with epithelial small-lamellar scales, while acquiring a rough surface. Sometimes these melanomas look like a scar with uneven edges. Sometimes they have a scalloped shape, which is whitish or pink in color. When an inflammatory corolla appears, swelling or itching occurs. Sometimes such a tumor is covered with sores.
Is it possible to treat this type of melanoma? According to experts, this form of pathology is the most dangerous because of its late diagnosis. Effective treatment is possible only at the first stage. And later, even with the adoption of the most radical measures, there is a relapse of the pathology with the development of metastases.
Spindle cell melanoma
The pathology received a similar name because of the characteristic shape of the cells, which is determined during a pathological or histological examination. Cells in neoplasms are located separately from each other and look like a spindle. At the same time, they intertwine cytoplasmic processes, forming bundles, clusters and strands.
The cells of such melanoma may have different shape and the number of cores. Melanin is concentrated, as a rule, in their processes. That is why such tumors have a mottled granular appearance.
nodular melanoma
This type of malignant neoplasm is in second place in terms of diagnosis, being detected in 15-30% of cases. These melanomas usually occur in people over 50 years of age. At the same time, they can be everywhere, but most often they are found in women on lower limbs, and in men - on the torso.
Such melanoma is characterized by an aggressive character and swift current passing through all stages in 0.5-1.5 years. Outwardly, it is distinguished by a round or oval shape. By the time the patient turns to a specialist, such melanoma already has the appearance of a plaque, which has clear boundaries, raised edges, and the color has become black, sometimes giving off blue. It happens that nodular melanoma increases to a significant size. Sometimes it takes the form of a polyp with an ulcerated or hyperkeratic surface.
Subungual melanoma
This neoplasm affects the skin of the feet and palms. Similar melanoma is diagnosed in 8-15% of visits. Most often, such neoplasms occur on the first toe or hand. At the same time, the tumor does not have a radial growth phase, which greatly complicates its diagnosis in the early stages of manifestation. Further, in the period from one to two years, melanoma spreads to the nail plate, acquiring a black or brown color. At the same time, it grows in a mushroom type and ulcers appear on it.
Removal of melanomas
The main method to get rid of a malignant neoplasm is its surgical, radio wave or laser excision. Removal of melanomas is performed by removing the affected area of the skin on the limbs or on the body. To do this, the surgeon marks the site at a distance of 3 to 5 cm from the visible edge of the tumor and excised it, while capturing the subcutaneous fatty tissue. If the melanoma is localized on the skin of the hands, face, or close to the natural opening, then the specialist designates a smaller area for removal. Its circumference is located 2-3 cm from the edges of the neoplasm. With the subungual form of melanoma, doctors perform exarticulation or amputation, and in the presence of a tumor in the middle and upper divisions auricles - removal of the latter.
With an existing ulcerated melanoma that has grown into the dermis, as well as in the presence of metastases in the nearest lymph nodes, the entire package of lymph nodes is removed along with the subcutaneous tissue.
Treatment
After the surgical intervention, therapy is carried out only in the presence of metastases or suspicion of them. How is melanoma treated? With the use of courses of immuno- and chemotherapy, as well as their combinations.
Strengthening the body's defenses is, as a rule, an additional treatment. It is inevitable with existing metastases or with their high risk of formation. The goal of immunology is to minimize the possibility of disease recurrence. And the combination of this method with chemotherapy allows you to exclude the spread of the tumor to other organs.
During the course, the patient is injected intravenously or intramuscularly with drugs such as Cyclophosphamide, Cisplatin, Dacarbazine, Carmustine or Imidazolecarboxamide. Treatment of neoplasms can also be carried out with the combined use of the above funds. This will prevent relapses.
Melanoma is distinguished by low sensitivity to radioactive radiation. That is why doctors prescribe radiation therapy only for symptomatic or palliative effects. Sometimes such methods are used when the patient refuses to surgical operation. Sometimes radioactive emissions patients go for preoperative preparation or after excision of melanomas.
After radical treatment, doctors put the patient on a permanent dispensary record. This will allow in the future to control the occurrence of a recurrence of cancer pathology and take timely measures to eliminate it.
Treatment effectiveness
To completely eliminate the problem, it is important to recognize the disease at the earliest stages of its development. So, at the first and second stages of the disease, the tumor is localized only in the primary focus. This allows you to get a positive outcome when taking all necessary measures in 99% of cases.
If melanoma has reached its third stage of development, then this means that metastases have already affected the lymph nodes. This development of the disease significantly aggravates the situation and gives a positive prognosis of only fifty percent.
Treatment success for melanomas that have reached their fourth stage is the least favorable. But it is still possible to overcome the disease. And this is confirmed by 40% of such patients.
Thanks
The site provides reference information for informational purposes only. Diagnosis and treatment of diseases should be carried out under the supervision of a specialist. All drugs have contraindications. Expert advice is required!
What is melanoma?
Melanoma is a type of malignant tumor that develops from pigment cells. In turn, pigment cells are cells containing pigment ( coloring) substance - melatonin. They are mainly found in the connective tissue of the epidermis ( i.e. in the skin) and in the iris, giving these organs a characteristic shade. In the cells of the tumor, a large amount of melanin accumulates, which gives it a characteristic color. However, there are, albeit extremely rare, non-pigmented or achromatic tumors. In the structure of cancer incidence, melanoma accounts for about 4 percent.
Caucasians are most at risk, in particular those with fair skin. This is due to several factors. One of the main ones is the reduction of the ozone layer in the atmosphere. Thus, it is known that the ozone layer located in the stratosphere ( upper atmosphere), delays most ultraviolet rays. Ultraviolet radiation is a type electromagnetic radiation, the main source of which is the Sun. It is with this type of radiation that the development of skin melanoma is associated. However, since the end of the last century, the ozone layer has decreased by 3 to 7 percent and continues to decrease annually. Researchers in this field suggest that every percent loss of the ozone layer is accompanied by an increase in the incidence of melanoma by one to two percent.
statistics on melanoma
Unfortunately, in recent decades there has been an increase in the incidence of this pathology. An analysis of the state of diagnosis of malignant skin diseases in the Russian Federation indicates a big problem of early diagnosis. So, at the first stage of the disease, only 30 percent of patients are detected. Every fourth ( 25 percent) a patient with melanoma is detected in advanced stages (third and fourth). This leads to the fact that the first-year mortality remains at a very high level. Thus, 10 to 15 percent of patients die within the first year of diagnosis.What does melanoma look like?
When describing melanoma, it is necessary to take into account the features of its possible localization. Melanoma is a tumor characterized by the highest variability of the clinical picture, which, in turn, determines its diverse course. Since the skin is the largest organ in the human body its area is about 2 square meters
) and it covers all the external organs, then the localization of the tumor can be anywhere. Nevertheless, there are also favorite places of localization - for women this is the place of the lower leg, for men it is the back and face. In more than half of the cases, melanoma develops at the site of congenital moles. If melanoma develops from previous pigmentation ( moles, nevus), then it can be located either in its center, or come from the periphery ( edges).
Variants of the appearance of melanoma are:
- flat pigment spot;
- mushroom-shaped, while it can be located on a leg or a wide base;
- slight protrusion;
- papillomatous growth.
Initially, the surface of melanoma is smooth and shiny, sometimes even as if it were a mirror. As the disease progresses, bumps, ulcerations appear on it ( small sores on the surface). The danger at this stage is that it starts to bleed at the slightest injury. Further, the tumor node can disintegrate with infiltration of the underlying tissues, as a result of which a formation resembling a cauliflower is formed on the surface of the skin. In rare cases, melanoma does not change and remains in the form of limited hyperemia ( redness) or a long-term non-healing ulcer.
melanoma consistency
The consistency of melanoma depends on its type and can vary from soft to firm and hard. At the same time, the consistency may be uneven - in this case, melanoma contains both soft and hard areas.
melanoma color
The color of melanoma depends on the amount of melanin in it ( pigment), with the exception of non-pigmented tumors. So, they can be brown, purple, purple or black, like ink.
Pigmentation may be uniform ( all melanoma is the same color) or uneven. In the second case, the tumor is more pigmented in the center, has a black rim around its circumference typical of melanoma. Often, melanoma has a variegated color, combining different shades.
A change in the color of an already existing melanoma is an alarming sign indicating an unfavorable and malignant course of the disease. In this case, a change in color can manifest itself in the form of darkening or, conversely, enlightenment. Moreover, pigmented melanomas can turn into non-pigmented melanomas and vice versa.
Nail melanoma and subungual melanoma
Nail melanoma is a type of melanoma that is localized near the nail bed or directly under the nail. It affects the nails on both fingers and toes. Today it is found among all age groups. Depending on the nature of growth, melanoma is divided into several types. Types of nail melanoma are:
- melanoma growing from the skin, next to the nail plate;
- melanoma growing directly from the nail plate itself;
- melanoma growing from the nail.
Subungual melanoma can be suspected in several cases. The first symptom indicating a tumor may be a change in the usual color of the nail plate. Although it should be noted that at this stage, nail melanoma is diagnosed extremely rarely. Also, under the nail, an initially small dark spot may form, which gradually increases in size. The spot may look like a longitudinal strip or have a rounded shape. Sometimes the color of melanoma can merge with the surrounding tissues. In this case, the raised shape of the nail may indicate the growth of melanoma. This is explained by the fact that as the melanoma grows, it pushes back the nail plate. In advanced cases, melanoma may be indicated by the formation of a nodule near the nail fold. Further, ulcers and erosion form on it. Like all types of melanomas, subungual melanoma is also prone to aggressive growth and rapid metastasis.
Melanoma of the eye
Melanoma of the eye is one of the most common malignant tumors, accompanied by decreased vision. It has a very aggressive and malignant course. Melanoma most often develops from choroid eyes, but melanoma and other elements of the eye also occur. Types of melanoma of the eye include:
- conjunctival melanoma;
- eyelid melanoma;
- choroid melanoma;
- iris melanoma.
The most rare species are conjunctival and eyelid melanoma. Unfortunately, early detection of melanoma is extremely rare. Indeed, in the early stages, the patient does not make any complaints. The main manifestation is small opacities on the retina. However, this can only be detected by ophthalmoscopic examination. That is, if the patient is periodically observed by an ophthalmologist, then in the course of routine studies, it is possible to detect melanoma in the first stage. At the second stage, complications already appear, such as pain in the eyes, swelling and redness of the eyelids. During the third stage, melanoma extends beyond the eyeball. Due to the ever-increasing size of the melanoma, the eye is displaced anteriorly. This phenomenon in medicine is called exophthalmos, and in the people "bulging eyes". The walls of the orbit are destroyed by a growing tumor, the integrity of the sclera is violated. At the fourth stage, bleeding into the vitreous body, clouding of the lens and other intraocular symptoms develop along with metastasis to the internal organs.
The main treatment is surgical removal of melanoma.
Melanoma on the face
The most malignant forms of melanoma appear on the face. In this case, they may have the form of a pigmented ( painted) or non-pigmented flat formation of various shapes. On the early stages it can be round or oval, sometimes even symmetrical. However, the more malignant the melanoma, the more uneven and blurred its outlines become. The same thing happens with color - in the initial stages, a uniform color is observed, but as it progresses, it becomes variegated. The shape can be flat, dome-shaped, in the form of a knot or a mushroom on a leg. melanoma on the back
In its course, melanoma on the back is no different from melanoma on other areas of the skin. The shape can also vary from round to domed, the color from dark blue to red. The disadvantage of such localization is that, due to the inaccessibility of the gaze, such melanoma is diagnosed at later stages. Unlike melanoma on the face, which delivers a visible aesthetic defect, patients with melanoma on the back go to the doctor much later. Symptoms ( signs) melanoma
The main sign of malignant melanoma is considered to be the growth of a pre-existing nevus or mole along the plane, a change in its edges and color, as well as the appearance of itching. If melanoma developed independently, then the main symptom will be the appearance of a pigment spot on the skin that has certain characteristics.Symptoms of malignant melanoma are:
- an increase in size or change in color of a nevus or mole;
- itching and bleeding of a nevus or mole;
- the appearance of a spot on the skin that bleeds slightly.
skin melanoma
So, melanoma can develop in all organs and tissues of the body ( oral mucosa, rectum, or eyes), but the most malignant are melanomas of the skin. They can have a different size, shape, texture and color. Initially, the size of melanoma can be negligible - in the initial stages, the diameter usually does not exceed one centimeter. However, the tumor can grow very quickly and in the final stages reach large tumor nodes.Melanoma can begin its development both from the previous nevus and independently. In the first case, a birthmark ( mole or nevus) begins to increase, change color and turns into a tumor. The growth of a mole into a tumor can begin with a previous injury ( it could be the slightest damage to the clothes) or after prolonged exposure to the sun. However, also the process of malignancy ( malignancy) may start spontaneously. There is a so-called malignancy rule, which includes four criteria. It is abbreviated as ABCD - an abbreviation made up of the first letters of the symptoms in English.
Signs of malignancy include:
- asymmetry ( asymmetry) - a previously symmetrical mole begins to lose symmetry and its edges become different and unlike each other;
- the edges ( border) - become uneven and intermittent;
- color ( color) - the color changes, a previously light or brown mole becomes black, while its color often becomes uneven - with inclusions of red and of blue color;
- diameter ( diameter) - the size of the mole increases, a diameter of more than 6 - 7 millimeters is considered to be potentially malignant.
Causes of melanoma development
Like most cancers, the causes of melanoma are still not well understood. Among the main risk factors, exposure to ultraviolet radiation on the skin and heredity predominates.Causes of melanoma include:
- ultraviolet radiation;
- hormonal imbalance;
- genetic predisposition.
To date, exposure to ultraviolet radiation ( spectrum of solar radiation) is recognized as the main cause contributing to the development of melanoma of the skin. However, it is important to understand here that not constant exposure to the sun is crucial ( i.e. chronic damage to the skin by ultraviolet rays) but a sharp, sometimes single, but intense effect of solar radiation.
Studies have confirmed that skin melanoma is more likely to develop in those individuals who spend most of their time indoors and rest, staying under the sun for a long time. At the same time, exposure to ultraviolet rays is closely related to skin type. According to most researchers, the incidence of skin melanoma is equally affected by ultraviolet radiation and ethnic factors. So, the fact that the tumor develops in people with fair skin is reliable. Statistical data indicate a rarer incidence of melanoma among people of the black race ( despite the fact that they have the same number of melanocytes in the epidermis as people with white skin). The main role in the pathogenesis of melanoma is played by a violation of the pigmentation of the body. The consequence of this is an abnormal reaction of the skin to solar radiation.
A violation of skin pigmentation can be judged on the basis of its color, as well as on the basis of the color of the hair and eyes. The presence of a large number of pigments on the skin can also indicate the level of pigmentation. age spots (scientifically nevi) and freckles. In such people, the usual short exposure to the sun is accompanied by burns. The classic melanoma patient is the owner of a light ( sour cream colors) skin, with many age spots and freckles, having straw-colored hair and blue eyes. Redheads are 3 times more likely to develop melanoma than fair-haired people.
Hormonal imbalance
Often the development of melanoma falls on periods accompanied by hormonal changes. This can be puberty in adolescents and menopause in women. So, under the influence of hormones, existing moles begin to regenerate - they increase in size, change shape and color.
genetic predisposition
The genetic factor is also one of the main reasons for the development of melanoma. It has been established that the risk of developing this pathology is increased in families suffering from atypical birthmark syndrome ( AMS - Atypical Mole Syndrome). This syndrome is characterized by the presence on the skin of a large amount ( more than 50) atypical moles. Already initially, these moles have features characteristic of malignant melanoma ( e.g. uneven edges, intensive growth). They are characterized by malignant degeneration, that is, the transition to malignant melanoma. Therefore, this syndrome is considered one of the main risk factors contributing to the development of skin melanoma.
Nevus, moles and other risk factors for melanoma
A nevus is a benign neoplasm that tends to become malignant. In the people, the nevus is called a mole or birthmark, which is not true. A nevus differs from a mole primarily in its size. It can be both congenital and acquired, appearing at certain life stages.A nevus is a dark lesion on the skin that can range in color from dark brown to purple. However, its color and size may change throughout life. Moles are subject to maximum changes during puberty. So, under the influence of hormones, they can increase in size, change shape and color.
Although a nevus is a benign and often harmless lesion, it is a risk factor for the development of melanoma. In people with multiple nevi, the risk of developing skin cancer is several times higher. Therefore, dermatologists advise monitoring the growth and number of nevi on the skin. Particular importance is attached to trauma to the nevi. So, cases of melanoma of the skin after their injury are described. It can be a single bruise, a cut or an elementary abrasion. Nevi can be chronically traumatized by clothes or shoes, which should also be taken into account.
Unfortunately, more than half of all primary melanomas of the skin develop against the background of nevi. This allows us to regard them as a precancerous condition. In this case, the frequency of malignancy ( malignancy) of nevi correlates with their size. For example, with a nevus larger than two centimeters, the risk of going into cancer is up to 20 percent. There are two main types of nevi - dysplastic and congenital. The former are part of the atypical syndrome and turn into malignant melanoma in 100 percent of cases. Congenital nevi occur in one percent of newborns. From acquired nevi, they differ in significant size and darker color.
Signs of dysplastic nevi are:
- more than half a centimeter in diameter;
- wrong shape;
- lack of clear boundaries and unclear outlines;
- flat surface;
- various shades - black, red, pink, red;
- uneven pigmentation ( the center can be one color, the edges - another).
Another risk factor for melanoma is Dubreu's melanosis. This syndrome is characterized by areas of skin pigmentation in middle-aged and elderly people. It is most often localized on the skin of the face, but can also develop in other areas of the body. The main signs of melanosis are uneven coloration and uneven edges. The contours of the pigment formation often resemble a geographical map. Dubrey's melanosis is distinguished by its scale - spots can reach up to 10 centimeters in diameter. Today, melanosis and nevus are usually regarded as a precancerous condition.
Types of melanoma
There are several types of melanoma classification. The main one is the TNM classification, which takes into account the stages of melanoma development and divides it into stages - from the first to the fourth. However, in addition to this, there is also a clinical classification, according to which there are four main types of melanomas. The types of melanomas according to the clinical classification include:
- superficial spreading melanoma;
- nodal ( nodular) melanoma;
- lentigo melanoma;
- peripheral lentigo.
Superficial spreading melanoma
The most common type of melanoma is superficially spreading melanoma, which occurs in 70 to 75 percent of cases. As a rule, it develops against the background of previous nevi and moles. Superficial melanoma is characterized by a gradual increase in changes over several years, followed by a sharp transformation. Thus, its course is long and, relative to other forms of melanoma, is non-malignant. It is more common in middle-aged people and affects both men and women equally. Favorite places of localization are the back, the surface of the lower leg. Not characteristic of superficially spreading melanoma big sizes.The characteristics of superficially spreading melanoma are:
- small sizes;
- wrong shape;
- uneven edges;
- polymorphic coloration interspersed with brown, red and bluish;
- is often ulcerated and bleeds.
Nodal ( nodular) melanoma
Unlike the previous tumor, the nodular ( synonymous with nodular) melanoma is less common, in about 15 to 30 percent of lesions. But, at the same time, it is characterized by a more malignant and aggressive course. It is not characterized by a long period of increase in symptoms - the disease proceeds at lightning speed. Most often, nodular melanoma develops on intact skin, that is, without previous nevi and moles. Initially, a dome-shaped dark blue nodule forms on the skin. Then it quickly ulcerates and begins to bleed. Nodular melanoma is characterized by vertical growth, that is, with damage to the underlying layers. Pigmentless nodular melanomas occur in 5 percent of cases. The prognosis for this disease is extremely unfavorable, affecting mainly the elderly.Lentigo melanoma or malignant lentigo
Lentigo melanoma ( synonym for melanotic freckles) occurs in 10 percent of cases, like the previous tumor, develops in old age ( most often in the seventh decade of life). Lentigo is often confused with freckles, which is not true. Initially, small nodules appear on the skin in the form of dark blue, dark or light brown spots, with a diameter of one and a half to three millimeters. Most often they affect the face, neck and other exposed areas of the body. Also, this type of melanoma can develop from benign Hutchinson's freckles. Melanoma grows very slowly in the superficial layers of the dermis. Until the moment of its penetration into the deeper layers of the skin, more than 20 years can pass. The prognosis is favorable.peripheral lentigo
Peripheral lentigo also accounts for about 10 percent of cases. It is more common in people of the Negroid race. The favorite localization of the tumor is the palms, soles and nail bed. The tumor is dark in color ( due to the presence of pigment), jagged edges. However, non-pigmented tumors can also occur. Peripheral lentigo grows slowly in the radial direction, as a rule, in the superficial layers of the skin without invasion ( germination) to the inner layers. Rarely, the tumor can penetrate into the deeper layers of the skin up to the subcutaneous fat layer. The prognosis depends on the degree of germination deep into the tumor.Pigmentary melanoma
In most cases, melanoma contains a coloring pigment - melatonin - which gives it a characteristic color. In this case, it is called pigment. The advantage of pigmentary melanoma is that it is easier to visualize ( that is to notice) and it brings a big cosmetic defect. This forces patients to see a doctor earlier.The color of pigmentary melanoma can vary and include a wide variety of shades - from pink to blue-black. The color scheme may change as the disease progresses. Moreover, the color may become inhomogeneous, which is an unfavorable sign. So, previously homogeneous melanoma in the third and fourth stages becomes variegated and contains various shades. Pigmentary melanoma may become pigmentless and lose its characteristic shade.
Non-pigmented melanoma
Pigmentless or amelanotic melanoma is the most dangerous tumor. It is called so because of the absence in it of the same coloring pigment that gives it color. The danger of non-pigmented melanoma lies not only in the fact that it is noticed late ( for a long time the tumor is not visible), but also in its aggressive growth. This type of tumor, regardless of stage, has a worse prognosis compared to a pigmented tumor. The tumor is a small tubercle that rises above the surface of the skin, the color of which does not differ from the rest of the skin. Amelanotic melanoma quickly grows deep and metastasizes in all known ways ( with the flow of lymph and blood). At the same time, as it grows, non-pigmented melanoma can turn into pigmented and acquire a dark shade. It should also be noted that the opposite happens when a pigmented tumor becomes pigmentless.Diagnosis of this type of tumor is a very difficult task. Diagnosis is difficult, especially when there are already nevi on the skin. The main diagnostic symptom is the rapid growth and discoloration of the neoplasm. However, the diagnosis is made on the basis of dermoscopic examination.
malignant melanoma
Initially, melanoma is a malignant tumor. Benign melanoma does not exist. A malignant tumor differs from a benign one in a number of ways.Signs of malignancy are:
- Rapid and uncontrolled growth. Tumor growth can be so intense that it leads to compression of surrounding tissues and organs.
- Tendency to invade germination) to neighboring organs and tissues and the formation of local metastases in them.
- The ability to metastasize- movement of tumor particles to distant organs with blood or lymph flow.
- The development of a powerful syndrome of intoxication ( "cancer poisoning"). This syndrome is characteristic of the later stages of the disease and is manifested by the penetration into the general bloodstream of dead tissues of the body.
- The ability to avoid immunological control of the body.
- Very low differentiation ( division) cells compared to healthy cells.
- Angiogenesis- the ability to create one's own circulatory system. So, at the later stages, the phenomenon of “vascularization” of the tumor occurs, which is characterized by the formation of new vessels inside the tumor.
- A large number of mutations within the tumor.
Stages of melanoma
In the development of melanoma, like other diseases, there are several stages. However, there are several options for classifying staging. Adherence to a particular classification often varies by country or region. However, there is a basic international classification that all specialists in this field use. Types of melanoma classifications include:
- international TNM classification- characterizes the size of the tumor, the presence of metastases;
- 5 stage classification- common in the west
- clinical classification- unlike the previous classifications, it describes only three stages.
Melanoma stages according to TNM
Criterion | Description |
|
T - degree of invasion(germination)melanoma in depth, the thickness of the melanoma itself is also taken into account | melanoma thickness less than one millimeter |
|
melanoma thickness from one to two millimeters |
||
melanoma thickness from two to four millimeters |
||
melanoma thickness more than four millimeters |
||
N - damage to the lymph nodes | one lymph node affected |
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two to three lymph nodes affected |
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more than four lymph nodes affected |
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M - localization of metastases | metastases in the skin, subcutaneous fat and lymph nodes |
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metastases in the lungs |
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metastases in internal organs |
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Early stages of melanoma
The initial or zero stage of melanoma is called melanoma in situ. At this stage, the tumor does not grow, being in the same place. It looks like a small mole of black color, it may contain blotches of red.first stage melanoma
According to the international TNM classification, melanomas of the T1–2N0M0 category belong to the first stage, which means that the thickness of the melanoma of the first stage varies from one to two millimeters, there are no metastases. According to the 5-stage classification, melanoma of the first degree is localized at the level of the epidermis and / or dermis, but does not metastasize through the lymphatic vessels to the lymph nodes. The thickness of the tumor is up to one and a half millimeters. According to the clinical classification, the first stage is a local stage.The characteristics of the first stage according to the clinical classification are as follows:
- a single primary neoplasm;
- satellites are allowed ( related to basic education) tumors within a radius of five centimeters from the primary tumor;
- the presence of metastases at a distance of more than five centimeters from melanoma.
second stage melanoma
According to the international TNM classification, melanomas of the T3N0M0 category belong to the second stage. This means that the thickness of melanoma in the second stage is from two to four millimeters, there are no metastases in the lymph nodes and internal organs. According to the Western 5-stage classification, the thickness of melanoma of the second stage varies from one and a half to four millimeters. At the same time, it extends to the entire dermis ( that is, on the thickest layer of the skin), but does not penetrate into the subcutaneous fat layer and into the lymph nodes. Clinical classification adds to all this also the defeat of regional ( local) lymph nodes.The third stage of melanoma
The third stage of melanoma is the categories T4N0M0 or T1-3N1-2M0. The first option describes a melanoma more than 4 millimeters thick, but without metastasis. The second option describes melanoma with a depth of one to four millimeters, with damage to two to three lymph nodes, without damage to internal organs.The characteristics of stage III melanoma according to the Western classification include:
- thickness more than 4 millimeters;
- germination of the tumor already in the subcutaneous fat layer;
- the presence of satellite additional) tumors within 2 to 3 centimeters of the primary tumor;
- metastasis to regional lymph nodes.
Fourth stage
The fourth stage of melanoma corresponds to the category T1-4N0-2M1, which means a tumor with a thickness of more than 4 millimeters, the presence of metastases in the lymph nodes and internal organs.melanoma in children
Unfortunately, one of the most malignant tumors occurs in childhood. At the same time, melanoma is observed among all age groups, but is most often recorded at the age of 4 to 6 years and from 11 to 15 years. It affects both boys and girls equally. Favorite localization is the neck, upper and lower limbs. Causes of melanoma in children
In more than 70 percent of cases in children, melanoma develops on altered skin, that is, against the background of existing nevi and moles. The most severe are melanomas that have developed against the background of large congenital nevi. In 10 percent of cases, melanoma is hereditary.Symptoms of melanoma in children
Symptoms of melanoma in children are polymorphic ( variable) and depends, first of all, on the form and stage of melanoma, as well as on its localization. Tumors in childhood are characterized by rapid and invasive ( germinating) growth.Signs of melanoma in children are:
- discoloration of a previous nevus or mole;
- proliferation of a previously “calm” nevus;
- elevation of education above the skin;
- the appearance of cracks;
- the appearance of a burning sensation and tingling;
- formation of ulcers ulceration phenomenon) followed by repeated bleeding;
- hair loss on the nevus and adjacent skin area.
The biological feature is resistance ( sustainability) tumors to chemotherapy and radiotherapy . So, despite the fact that there have long been standard schemes chemotherapy in the treatment of melanoma in adults, they are not applicable for children. Although recently new regimens have been developed for the treatment of malignant melanoma among children, despite this, the main method of treatment has been and remains the surgical method.
Prognosis for melanoma
The main condition for successful remission in melanoma is its early diagnosis. Early detection of malignant melanoma depends primarily on the level medical care and from the knowledge of the doctor. At the same time, patient awareness is important. All persons with precancerous conditions ( nevi, melanosis) should periodically undergo preventive examinations by a family doctor and a dermatologist. In Australia ( where is the highest incidence of melanoma) a program was adopted, according to which the signs of malignant skin tumors and malignancy of moles are studied in general education school. Thus, a simple resident with a mole or nevus is able to notice the first signs of a transition to cancer. During this program, it was possible to increase the 5-year survival rate ( main criterion for remission) in melanoma. This was achieved by the fact that patients themselves sought advice from a dermatologist at the slightest change in moles. Thus, an early diagnosis of melanoma was achieved.Metastases in melanoma to the brain and lymph nodes
The lymphatic system is a unique defense system of the body that has representation at every level. It is represented by three components - lymphoid tissue, lymphatic vessels and the lymphatic fluid in them ( lymph). Lymphatic tissue is distributed throughout the body, being in almost every organ, in the form of lymph nodes. That is why the lymph nodes become the main target for metastasis ( dissemination) tumors and melanoma are no exception in this case.Wherever melanoma is located, as it progresses, it always metastasizes to the lymph nodes. This happens already at the second stage, when the melanoma begins to ulcerate and becomes loose, as a result of which the tumor cells enter the lymphatic capillaries ( that are everywhere). From the capillaries, along with the liquid, cancer cells enter the nearest lymph nodes. In it, the cells settle and begin to multiply, forming a secondary focus in the lymph node. During this period, the tumor process is suspended for a while. However, the lymph node damaged by cancer cells continues to grow up to a certain stage. Then it becomes loose again, and the tumor particles from it through the lymphatic capillaries reach another, more distant lymph node. The farther from the primary focus, the more neglected the disease is considered.
With melanoma, the cervical, axillary and intrathoracic nodes are most often affected. Symptoms of the lesion are polymorphic ( diverse) and depends on the number of affected nodes, the degree of their compression.
Metastases in the cervical lymph nodes
In a healthy person, this group of lymph nodes is outwardly not noticeable and not palpable. But due to the enlargement of the lymph nodes in the neck, round or oval formations are visually determined ( the number of formations depends on the number of affected lymph nodes). The skin above them is not changed, which is an important diagnostic feature. To the touch they are dense, motionless, often painless. If deep cervical nodes are affected by metastases, then visually they are not marked in any way. At the same time, an asymmetric thickening of the neck appears.
Metastases in the axillary lymph nodes
Patients with axillary lymph node metastases complain of feeling foreign body in the armpit, as if something were disturbing them. AT armpit lymph nodes are located along the vessels and nerves. If the lymph node is located near the nerve, pain, numbness of the arm, or tingling of the skin may occur. When squeezing the blood vessels, swelling of the hand develops.
Metastases in intrathoracic lymph nodes
In the cavity of the chest is a large number of lymph nodes, which are called intrathoracic. Symptoms of the defeat of these lymph nodes depend on their location and size.
Symptoms of metastases in the intrathoracic lymph nodes include:
- persistent cough;
- difficulty in swallowing;
- violations of the rhythm and conduction of the heart;
- hoarseness of voice.
Metastases in the lymph nodes of the abdominal cavity
The clinical picture of abdominal metastases, as in the cases described above, will depend on which lymph nodes were affected. So, metastases in the mesentery of the intestine are accompanied by intestinal colic, constipation, and in severe cases, intestinal obstruction. Metastases in the liver are accompanied by stagnation venous blood in organs, with the development of edema and ascites ( accumulation of fluid in the abdominal cavity).
Metastases to the brain
Unfortunately, brain metastases are not uncommon. Today, more than 30 percent of cancer patients have brain metastases. About one fifth of all intracranial metastases are melanoma ( lung and breast cancer are the first in brain metastasis). Penetrating into the brain metastases give a specific clinical picture.
Symptoms of brain metastases are:
- Nausea. It can be a sign of both intoxication and intracranial pressure. In the second case, as the pressure increases, vomiting also joins. Nausea combined with headache is an unfavorable symptom.
- Bursting headaches. Initially, headaches are mild and resolve with analgesics. Then they become permanent and do not respond to pain medication. Headaches are often accompanied by dizziness and visual disturbances. Often this is the first symptom that speaks of brain damage.
- convulsive syndrome, which is manifested by large and small seizures of the type of epileptic. Typical for patients over 45 years of age.
- Focal symptoms, which is individual and depends on the location of metastases. So, metastases in the right hemisphere are manifested by disorders of the sensitivity of the left arm and leg. Metastases in the temporal region are accompanied by hearing impairment, in the occipital region - visual impairment.
Diagnosis of melanoma
Diagnosis of melanoma, like other diseases, is to collect an anamnesis ( medical history), inspection and appointment of additional studies. The collection of anamnesis in the diagnosis of malignant melanoma occupies an important place. So, during the survey, the doctor is interested in when the changes appeared, how they started, how quickly the mole grew and whether it changed color. Family history ( hereditary diseases ) is no less important. Today obligate ( compulsory) precancerous disease is considered atypical birthmark syndrome. In families where family members suffer from this syndrome, the risk of developing melanoma is increased several dozen times. Data on previous trauma, prolonged exposure to the sun are important.
Melanoma checkup
Next, the doctor proceeds to the examination. Particular attention is paid not only to melanoma, but also to adjacent areas of the skin. There are certain signs of malignant melanoma on which the diagnosis is based.Diagnostic criteria for malignant melanoma are as follows:
- neoplasm unevenly protrudes above the surface of the skin;
- numerous erosions and bleeding sores;
- maceration ( softening);
- ulceration of melanoma;
- development of associated nodules ( is a sign of metastasis);
- melanoma color variation - includes areas of red, white and blue on a brown or black background;
- color enhancement along the periphery of the melanoma, resulting in a ring of coal-black merging nodules;
- an inflammatory corolla can also form around the contour of the melanoma;
- in the area of melanoma, the skin pattern completely disappears;
- uneven edge with corners and notches;
- blurred outline borders.
Questions that a dermatologist asks during a consultation may include:
- Has the size changed? This takes into account the rapid growth of an old or newly formed mole. Formations larger than 7 millimeters are subject to special examination.
- Has the form changed? A previously rounded mole acquires irregular contours.
- Has the color changed? The appearance of various brown, red and blue shades on an old or new mole.
- Have there been signs of inflammation before? Zones of hyperemia appear around the contour of the mole ( redness).
- Is the release of moisture and bleeding characteristic?
- Is there itching and peeling?
What tests and studies are prescribed for melanoma?
Despite the fact that the diagnosis sometimes lies on the surface, the attending physician, as a rule, prescribes additional tests and studies. This is done to exclude or confirm, first of all, metastases to regional lymph nodes and systemic metastases ( i.e. metastases to internal organs). This requires an additional general examination of the patient, as well as studies such as a chest x-ray and a scan of the bones of the skeleton.Additional studies in the diagnosis of melanoma are:
- general inspection- during a general examination, the doctor palpates the patient's lymph nodes, determines their soreness, density, adhesion to tissues;
- chest x-ray ( enroll) - in order to determine if there are metastases in the intrathoracic lymph nodes;
- skeletal bone scan- to exclude the same metastases;
- blood chemistry with determination of lactate dehydrogenase activity ( LDH) and alkaline phosphatase - an increase in the level of these enzymes indicates melanoma metastasis, it can also indicate resistance ( sustainability) tumors for treatment;
- ultrasound procedure ( ultrasound) abdominal organs ( enroll) carried out to analyze the state of internal organs and lymph nodes, it is recommended for patients with melanoma thickness of more than one millimeter;
- dermatoscopy ( enroll) - a method that allows using a special device ( on a device similar to a microscope and connected to a computer) increase the suspicious formation hundreds of times and examine it in detail.
Melanoma ICD10
According to the international classification of diseases of the tenth revision ( ICD-10) malignant melanoma of the skin is coded C 43. The localization of the tumor is further explained by an additional figure, for example, malignant melanoma of the eyelid - C43.1.ICD-10 code | Localization of melanoma |
C43.0 | Malignant melanoma of the lip |
C43.1 | Malignant melanoma of the eyelid |
C43.2 | Malignant melanoma of the ear and external auditory canal |
C43.3 | Malignant melanoma of other parts of the face |
C43.4 | Malignant melanoma of the scalp and neck |
C43.5 | Malignant melanoma of the trunk |
C43.6 | Malignant melanoma of the upper extremities |
C43.7 | Malignant melanoma of the lower extremities |
C43.8 | Malignant melanoma of other parts of the body |
C43.9 | Unspecified malignant melanoma of the skin |
How to distinguish melanoma?
In order to correctly distinguish melanoma and notice the first signs of malignancy, it is necessary to distinguish between skin formations, that is, to know the difference between freckles, moles, nevi. Unfortunately, even many experts confuse these definitions with each other.Characteristics of Common Skin Lesions
Name | Definition |
Freckles | Flat light brown round spots on the skin, darkening in the sun and turning pale in winter. |
Moles | Oval or rounded formations, dark brown or flesh-colored. The diameter of moles varies from 0.2 to 1 cm. As a rule, moles are flat, but sometimes they can rise above the level of the skin. |
Atypical or dysplastic nevi | Larger moles, with jagged edges and uneven coloring. |
malignant melanoma | Pigmented and non-pigmented formations on the skin that occur both independently ( de novo), and on altered skin ( i.e. from previous moles). Melanoma develops from pigment cells ( melanocytes) skin. Further growing deeper, the tumor acquires the ability to metastasize through the lymphatic and blood vessels to any part of the body. |
Melanoma research methods are:
- tumor indication by radioactive phosphorus;
- cytological examination;
- thermal differential test;
- biopsy ( enroll) .
The method is based on the intensive accumulation of radioactive phosphorus by the tissues of a growing malignant melanoma.
Cytological examination
This method is simple and highly effective in determining the nature of melanoma and its metastases. Cytology involves the study of tissue for cell morphology. This examines the structure of the cells that make up the melanoma. The reliability of the study is more than 95 percent. Pieces of lymph nodes should also be taken for cytological examination in order to determine metastases in them.
Thermal differential test
This test is based on the temperature difference between a melanoma site and a symmetrical area of healthy skin. It is carried out by measuring the temperature of each affected area with a thermometer. If the average temperature difference is more than 1 degree, then the test is considered positive.
Biopsy
As a diagnostic method, biopsy today deserves special attention. For a long time it was believed that due to the high risk of metastasis, this method is not applicable in the diagnosis of melanoma. However, recent studies have shown that biopsy is a very valuable method in identifying early forms of melanoma.
The principles of a biopsy are as follows:
- the excision is made in the form of an ellipse, since with a circular excision the thickness of the tumor may be incorrectly estimated;
- when performing a biopsy, the injection needle should not be inserted into the melanoma itself;
- melanoma is excised, departing from the edge by two millimeters.
Which doctor treats melanoma?
The main specialist in diagnosing and subsequently treating melanoma is oncologist ( enroll) . Since melanoma is a tumor, it is treated by a doctor who treats tumor diseases. However, melanoma may initially be suspected dermatologist ( enroll) or family doctor ( therapist) (enroll) . Consultation may be needed to confirm hereditary atypical spot syndrome genetics ( enroll) .Melanoma treatment
Treatment of melanoma, like any tumor, involves surgery, radiotherapy and chemotherapy. However, the choice of treatment method depends solely on the characteristics of melanoma and its stage. At the same time, it should be noted that melanoma is poorly sensitive to radiotherapy and does not always respond to chemotherapy. Melanoma treatments are as follows:
- surgical treatment, which involves excision of the tumor;
- chemotherapy;
- radiation therapy;
- biological therapy ( immunotherapy).
Stage | Treatment method |
initial stage(0 ) | It involves excision of the tumor with the capture of up to one centimeter of healthy tissue. Further, only observation by an oncologist in dynamics is recommended. |
Stage I | Initially, a biopsy is performed, followed by excision of the tumor. In this case, the capture of healthy tissue is already 2 centimeters. If there are metastases in the lymph nodes, then they are also removed. |
Stage II | Surgical treatment and chemotherapy are used. Initially, a study is carried out on the defeat of lymph nodes by metastases. Next, a wide excision of the melanoma is performed ( capture of healthy tissue by more than 2 centimeters), followed by removal of the lymph nodes. At the same time, the removal of melanoma and lymph nodes can take place in one or two stages. After removal, chemotherapy follows. |
Stage III | Chemotherapy, immunotherapy, tumor excision are carried out. A wide excision of melanoma is also performed, in which healthy tissue is captured by more than 3 centimeters. This is followed by regional lymphadenectomy - removal of lymph nodes located near the primary focus. Treatment ends with chemotherapy. For the resulting defect after the removal of melanoma and adjacent tissue, plastic surgery is used. |
Stage IV | There is no standard treatment. Radiation therapy and chemotherapy are used. Operational ( surgical) treatment is rarely used. |
Chemotherapy for melanoma
In the treatment of melanoma, polychemotherapy is often used, which is based on the use of several drugs at the same time. The most commonly used drugs are bleomycin, vincristine, and cisplatin. So, for each type of melanoma, their own schemes have been developed.The most common treatment regimens are as follows:
- Roncoleukin 1.5 mg intravenously every other day in combination with bleomycin and vincristine. It is carried out in 6 cycles at intervals of 4 weeks.
- Roncoleukin 1.5 mg intravenously every other day in combination with cisplatin and reaferon. Similarly, 6 cycles at intervals of 4 weeks.
Surgical treatment of melanoma
As already described, in the surgical treatment of melanoma, a wide excision is used. The purpose of this method is to prevent the development of local tumor metastases. For the resulting defect, plastic reconstruction is used.The amount of tissue removed depends on the size and shape of the tumor. So, with superficially spreading and nodular melanoma, excision is performed, departing from its edge by 1 - 2 centimeters. Excision in this case is carried out along an ellipse, giving the block of excised tissues an ellipsoidal shape. The plasty of the resulting defect takes place in two stages. First with a synthetic absorbable material ( vicryl or polysorb) sutured the dermis. Then the second intradermal suture is adjusted, using non-absorbable threads ( e.g. nylon).
Wide excision is excluded in the treatment of lentigo melanoma. Instead, cryodestruction and laser destruction are used. In the first case, the tumor is destroyed when exposed to extremely low temperatures. In the second case, tumor cells are destroyed under the influence of a laser.
Radiation therapy
Radiation therapy or radiotherapy is not the primary treatment for patients with melanoma. This is explained by the low sensitivity of the tumor to ionizing radiation. Therefore, the application of this method in the form self-treatment melanoma is possible only when the patient categorically refuses the operation. In other cases, radiation therapy is used in the postoperative period or as a combined method of treatment.Patient follow-up
Patients who have completed radical surgery should be followed up by an oncologist. Observation should be carried out according to the general rules - periodic examinations by a doctor, with the performance of control ultrasound examinations.The rules for dispensary observation of patients with melanoma are as follows:
- during preventive examinations, a mandatory examination of the skin in the area of the removed tumor;
- Skin diseases (face, head and other parts of the body) in children and adults - photos, names and classification, causes and symptoms, description of skin diseases and methods of their treatment
Cancer is a pathology that can affect any organs and tissues. The skin is also an exception. The appearance of small moles and pigmented spots can often represent a cancerous formation - melanoma.
Over the years, the number of people with this type of cancer is constantly progressing, and today 40 people out of 100 thousand cancer patients fall ill with this pathology.
Melanoma is a cancerous growth on the surface of the skin and is one of the aggressive forms. If left untreated, she metastasizes quickly involving adjacent organs and tissues in the pathological process.
Most often, the disease is diagnosed in people of the age group 30–50 years old. Unlike other types of cancer, melanoma is easily diagnosed, even at the initial stages of development.
Statistics
Melanoma is a fairly rare disease. Of the total number of cancer patients, only 2.3% are diagnosed with skin melanoma. If we consider this pathology among all cancerous skin diseases, then melanoma is detected in 13% of cases.
Treatment of melanoma in the early stages is characterized by a positive prognosis and stable remission in 95% of patients.
The reasons
The causes that provoke the development of melanoma of the skin differ in nature and diversity:
- low content of melanin in the body;
- observed predisposition of people with red hair and freckles;
- genetic predisposition;
- the presence of a large number pigment formations(more than 50 pieces all over the body);
- skin dermatitis or its precancerous pathologies;
- age over 50;
- regular sunburn or UV training;
- exposure to carcinogenic sources of training: solariums, quartz lamps;
- systematic injuries in the area of moles or pigmented areas;
- expressed weakening of the immune system.
Symptoms
The peculiarity of melanoma of the skin is that at the beginning of its development, it practically does not give itself away. In a separate area, in the basal layer of the skin appears little education, no more than 0.5 cm in diameter.
Depending on the form of education, cancer can have different symptoms. It is possible to distinguish a newly appeared malignant formation from an ordinary mole or a mole by the following symptoms:
- most often education has a dark uneven color. But in isolated cases, a pigmentless formation is diagnosed;
- tumor surface is different homogeneous dense structure and shiny surface;
- in the affected area no vegetation;
- margins of melanoma often serrated and do not have clear boundaries.
In the case of cancer of the mole, the following changes are observed:
- surface shade changes to darker;
- mole starts quickly increase in size and change their shape;
- noted hair loss from a nevus or mole, as well as in the surrounding area.
In addition to the listed signs, both the first and the second forms are characterized by common symptoms:
- with time, the surface becomes "varnished", acquiring an unnatural shine;
- noted the tendency of the tumor to disintegrate;
- in the center of the affected area ulcers are formed;
- slight mechanical impact to tumor bleeding;
- pathological formation begins to itch constantly;
- noted on palpation severe pain;
- education is growing simultaneously both in depth and in width;
- tumor acquires a complete asymmetry.
In this video, doctors named 5 main signs of melanoma that you should definitely pay attention to:
Diagnostics
Diagnosis of the initial stage of pathology development is carried out according to a standard plan, including the following research methods:
- visual inspection and collection of clinical data. It is used during the initial treatment and allows you to form a general picture of the disease;
- excisional- taken directly from the affected area to detect cancer cells;
- incisional biopsy. It is intended for histological examination, for which not only affected, but also healthy tissues are taken;
- CT or MRI allows you to determine the size of the tumor, the degree of damage to adjacent tissues, due to the layered image of the formation;
- confocal microscopy. It is used to determine the stage of the disease, using a special microscope.
dermatoscopy- is carried out using a special device equipped with magnifying optics. The device makes it possible, through magnification, to examine in detail the stratum corneum of the epidermis.
Some clinics use a digital version of this device. In addition to the appearance of the skin surface, it allows you to create a three-dimensional model of a malignant neoplasm;
About the methods of self-diagnosis of the disease is described in this video:
Treatment
For the treatment of melanoma in the early stages, certain methods or a combination of them are used.
As a fundamental method, surgery. To consolidate the result and reduce the likelihood of relapse, a complex is prescribed, including chemotherapy and radiation exposure.
Surgery
Removal of melanoma surgically, shown at small growths. This procedure can be carried out even on an outpatient basis, as it does not require special equipment and general anesthesia.
The procedure is carried out step by step:
- Before removal, the patient inject a local anesthetic injection method, in the affected area.
- Then, using a scalpel, a neat excision of malignant tissue with the capture of 1 or 2 cm of healthy skin located around the formation.
- Next is carried out additional biopsy, after which the wound is treated with a hemostatic and aseptic preparation.
- Finally, to the operated area a tight aseptic bandage is applied.
Conservative treatments
Conservative techniques for skin cancer are used only in combination and most often act as methods that complement surgical treatment.
The following are used as conservative methods:
Chemotherapy. This method is not used as an independent treatment due to its low efficiency. Clinical observations have shown that after chemotherapy, improvement occurred in only 2% of patients. Chemotherapy is the administration of certain drugs that are active against cancer cells.
The drugs are injected into the general circulation or a localized area, due to which they have not only an anti-inflammatory, but also a pronounced negative effect. For the relief of melanoma, drugs such as carmustine or dacarbazine are most often used.
Also, the use of cisplatin, tamoxifen, cyclophosphamide and lomustine is allowed. The procedure with these drugs can be carried out both regionally and systemically.
Radiation therapy. It implies an effect on the formation of radiation rays. The dosage, scheme and number of exposures is determined depending on the volume of growth, the age of the patient and the characteristics of his body.
Treatment can be carried out externally and internally. With internal, a small needle or catheter is inserted into the affected skin, through which radiation is supplied. With an external method, a radioactive beam from a special device is placed on the pathological area, which is pulsed.
radiological treatment. Most often used only before surgery, as a therapy to reduce the size of the tumor. After the operation, it is prescribed only in combination with other methods.
This method is an impact on the tumor by point radiological irradiation. It allows you to guarantee the stabilization of the malignant process and is a good prevention of recurrence of the pathology.
Forecast
At the initial stage of the disease, the tumor is only superficial, without penetration into the deeper layers of the skin and metastasis. Treatment in this case is easy to predict.
As a rule, with a formation thickness of not more than 1 mm, the treatment has positive results in 100% of cases.
Observation of the pathology for 5 years shows a complete recession in 97% of patients. If the tumor had a size of about 1.5 mm, then the treatment shows positive results in 95% of cases. Recession is observed only 85% of them.
The rehabilitation period after surgery takes only a few days. After chemotherapy or radiation therapy, this period may be a month or more.
To reduce the recovery time and reduce the likelihood of relapse, it is recommended to adhere to the following rules:
- during the rehabilitation period, you should support your body immunotherapy. But it should be borne in mind that all drugs should be selected only by an oncologist. Most often, interferon-alpha, interleukin-2 and the granulocyte-macrophage component of a colony-stimulating nature are prescribed;
- in the future, it is necessary avoid prolonged exposure to the sun and exposure to direct sunlight;
- it does not follow visit a solarium and ultraviolet irradiation, even for preventive purposes;
- it is necessary to protect moles and similar formations from chafing and permanent injury
- at the slightest change in formations, it is necessary contact a doctor immediately.
Melanoma is a very aggressive malignant tumor resulting from the degeneration of pigment cells (melanocytes and melanoblasts) that produce the pigment melanin. The cells of such a tumor contain a large amount of melanin, which causes their coloration in dark colors, but there are also non-pigmented variants (in a small percentage of cases).
Epidemiology
Incidence. Melanoma is about 10 times less common than skin cancer. It is about 1% of total number malignant tumors. In European countries, during the year, this tumor occurs in 2-4 people per 100,000 population. The incidence of melanoma has been on the rise in recent years.
Age and gender characteristics. Melanoma occurs more frequently in women than in men. The differences are insignificant, but melanomas of the lower leg, rear of the foot and forearm in women are observed 3 times more often than in males. The incidence of melanoma increases sharply in the age group of 30-39 years, then there is a gradual, slow increase in the frequency of the tumor up to advanced age.
Epidemiological patterns. Melanoma is characterized by the same geographical distribution patterns as skin cancer. The incidence is higher in southern countries and regions. More often, people with fair skin get sick. In the US, melanoma is 7 to 10 times more common in whites than in blacks. In Kazakhstan and Kyrgyzstan, the morbidity of the visiting population is 3-4 times higher than that of the native population. The likelihood of developing a tumor increases in direct proportion to the time spent outdoors, in the sun.
Etiology
Previous diseases
Melanoma usually develops from acquired and congenital nevi and Dubrey's melanosis. Pigmented nevi occur in 90% of people. Depending on the skin layer from which they develop, epidermal-dermal, or borderline, intradermal and mixed nevi are distinguished. The most dangerous are borderline nevi. They are a well-defined nodule of black-brown, black-gray or black color with a smooth, dry surface, on which there is no hair. The nodule is flat or slightly elevated above the skin surface, painless, has a soft-elastic texture. Sizes vary from a few millimeters to 1 cm. Border nevus is usually localized on the head, neck, palms and feet, and trunk. The frequency of malignancy (malignancy) of mixed nevi is much lower, and melanoma develops from dermal nevi in isolated cases.
Surgery for nevi was previously considered dangerous. This notion turned out to be wrong. Currently, it is believed that excision of any and even borderline nevus within healthy tissue (departing 0.5 cm from the edges) guarantees recovery and is a reliable measure for the prevention of melanoma. It is especially recommended to remove nevi located on the sole, foot, nail bed, in the perianal region, which are almost always borderline in their structure and are often injured.
Predisposing factors
The transformation of pigmented nevi into melanoma is facilitated by trauma, ultraviolet radiation and hormonal changes in the body. The last two factors may also influence the occurrence of melanoma on intact skin.
The role of trauma is beyond doubt. Approximately 40% of patients with melanoma develop signs of malignancy soon after an accidental or intentional injury to the pigmented nevus. Sometimes it is enough to tie a thread or cut off a nevus with a razor to cause rapid growth and malignancy of the tumor. Insolation is associated with a greater frequency of melanomas in southern countries and regions, as well as frequent occurrence tumors on exposed parts of the body.
The conclusion about the role of endocrine influences is speculative, based on the fact that melanomas rarely occur before puberty, and during puberty, pregnancy and menopause, acceleration of tumor growth is sometimes observed. It is also confirmed by the fact that individual cases a change in hormonal status leads to inhibition and even regression of the tumor.
Pathological characteristics
Localization
Unlike skin cancer, the predominant location of melanoma on the face is not observed. In almost half of the patients, the tumor occurs on the lower extremities, somewhat less frequently on the trunk (20-30%) and upper limbs (10-15%), and only in 10-20% - in the head and neck.
Growth and distribution
The growth and spread of melanoma occurs by germination of surrounding tissues, lymphogenous and hematogenous metastasis. Melanoma grows in three directions: above the skin, along its surface and deep into, successively sprouting layers of the skin and underlying tissues. The deeper the cords of tumor cells spread, the worse the prognosis. Germination of skin layers is detected by microscopic examination of the removed area. Depending on the depth of damage to the layers, according to the classification proposed by Clark, 5 levels of invasion are distinguished. At 4-5 levels of invasion, the prognosis is worse.
Of great prognostic value is the thickness of the neoplasm. Melanomas with a thickness of less than 0.76 mm proceed most favorably. With an increase in the thickness of the neoplasm, the prognosis worsens.
Metastasis
Melanoma is characterized by rapid and early metastasis. Most often, metastases affect regional lymph nodes. Metastases to distant lymph nodes are less common. Affected lymph nodes are dark in color with a dense elastic consistency, their size varies from 1-2 cm to large tumor conglomerates.
Skin metastases are common. They have the form of small multiple, brown or black rashes slightly rising above the level of the skin. Metastases are located near the primary focus, in connection with which they are called satellites. Metastasis to the skin can occur as a diffuse infiltration of the skin with melanoma cells. In such cases, the skin becomes slightly swollen, painful, acquires a bluish-red tint.
Hematogenous metastases can occur in any organ, but the lungs, liver, brain, and adrenal glands are most commonly affected. Usually, metastases are multiple and may be accompanied by the appearance in the blood and excretion of free melanin (chalk) in the urine.
Classification
TNM classification
- Primary tumor (T)
- T is - melanoma in situ
- T 1a - melanoma ≤ 1 mm thick, Clark level II-III, no ulceration
- T 1b - melanoma ≤ 1 mm thick, Clark level IV-V or with ulceration
- T 2a - melanoma 1.01 - 2.0 mm thick without ulceration
- T 2b - melanoma 1.01 - 2.0 mm thick with ulceration
- T 3a - melanoma 2.01 - 4.0 mm thick without ulceration
- T 3b - melanoma 2.01 - 4.0 mm thick with ulceration
- T 4a Melanoma > 4.0 mm thick without ulceration
- T 4b Melanoma > 4.0 mm thick with ulceration
- Regional lymph nodes (N)
- N 0 - no metastases to regional lymph nodes
- N 1 - metastasis in 1 lymph node / li>
- N 1a - determined only microscopically
- N 1b - visible to the naked eye
- N 2 - metastases in 2 - 3 lymph nodes
- N 2a - determined only microscopically
- N 2b - visible to the naked eye
- N 2c - satellite (these are small 0.05 mm in diameter foci that form in the dermis around the main tumor) or transient metastases
- N 3 - metastases in 4 lymph nodes, transient or satellite metastases
- Distant metastases
- M 0 - no distant metastases
- M 1a - metastases to the skin, surrounding tissues or distant lymph nodes
- M 1b - metastases of melanoma in the lungs
- M 1c - distant metastases with an increase in LDH (lactate dehydrogenase)
- R 0 - no recurrence
- R 1 - microscopic recurrence
- R 2 - macroscopic recurrence
Stages of melanoma
In clinical practice, a relatively simple classification is used:
- Stage I - melanoma up to 2 cm in size in the largest diameter, germinating only the skin, without metastases to the lymph nodes;
- Stage II - pigmented tumors larger than 2 cm with infiltration of the underlying fiber;
- IIa - without enlargement of regional lymph nodes;
- IIb - with enlarged lymph nodes, suspicious for the presence of metastases; - Stage III - tumors of various sizes and shapes, germinating subcutaneous tissue and aponeurosis, limited displacement;
- IIIa - without metastases to the lymph nodes;
- IIIb - with metastases to regional lymph nodes; - Stage IV - a tumor of any size with satellites, or with multiple metastases in regional lymph nodes, or with distant metastases.
Symptoms
Melanoma is initially a dark spot that rises slightly above the surface of the skin. In the process of growth, it takes the form of an exophytic tumor, which can ulcerate in the future. The tumor is usually solitary; primary-multiple foci are very rare. Depending on the growth rate and the time of visiting a doctor, the size of melanoma varies from a barely noticeable point to large nodes, reaching an average size of 1.0–2.5 cm.
The consistency of the neoplasm is elastic, sometimes moderately dense. The surface is often smooth, but may be bumpy with papillary growths in the form of cauliflower. The shape is round or oval, in the presence of papillary growths becomes irregular. An exophytic tumor is usually located on a wide base, less often on a narrow stalk, acquiring in these cases a mushroom shape.
Three characteristic features play a role in the recognition of melanoma: dark coloration, a shiny surface, and a tendency to decay. These features are due to the processes occurring in the tumor: the accumulation of pigment, the defeat of the epidermal layer, the fragility of the neoplasm.
Dark color makes it relatively easy to distinguish melanoma from other malignant tumors, but it also leads to great difficulties in differential diagnosis with pigmented nevi. The color intensity depends on the amount of melanin in the tumor. Usually, melanomas are a rich dark color with varying shades from dark brown or bluish black to slate black. Less common tumors are light brown or reddish-purple. In some cases, unstained neoplasms, the so-called pigmentless melanomas, are observed.
When viewed with the naked eye, the color of the tumor seems to be uniform, but sometimes the pigmentation is more pronounced in the center, or vice versa, the relatively light central part may be surrounded by an intensely pigmented rim at the base. Finally, in some patients, the pigment is scattered over the entire surface in the form of isolated grains. When viewed under magnification, a network-like surface pattern and variegated heterogeneous pigmentation of varying intensity with a bluish, brown or black tint of grains are almost always found.
The disappearance of the skin pattern and the shiny nature of the surface are the second hallmark of melanoma. The epidermis over the tumor is thinned, as if stretched, unlike nevi, there is no skin pattern, due to this, the surface of the melanoma appears smooth, mirror-like. This feature is also observed in non-pigmented neoplasms, which sometimes facilitates their recognition.
Tumor destruction occurs in late stages. The loose and not very dense tissue of melanoma is easily injured and disintegrates. Minor injuries lead to a violation of the integrity of the tumor and are accompanied by bleeding. A careless movement, rubbing of clothes, an accidental, not very rough touch is enough to damage the tumor and cause bleeding. A crust forms at the site of injury. Sometimes patients take it off. The crust is removed easily, but bleeding occurs again.
As a result of trauma or without any intervention, a site of decay or ulceration occasionally appears on the surface of the melanoma. Its surface is covered with crusts, bloody or purulent discharge can be released from under them.
Diagnostics
The diagnosis of melanoma in many patients presents significant difficulties. To make a diagnosis, it is necessary to take into account complaints, the dynamics of the development of the disease and the data of an objective study. Valuable information can sometimes be obtained using special research methods.
Interview
Patients with melanoma complain of the appearance or increase in pigment formation, its weeping, bleeding, slight burning, pruritus or dull pain in the area of the tumor.
When collecting an anamnesis, the doctor is faced with the task of assessing the dynamics of the disease. To do this, you need to find out:
- whether the pigmented formation is congenital or acquired;
- what form it had at the beginning, what changes and over what period of time occurred;
- whether the changes that have occurred are related to accidental injury or prolonged exposure to the sun;
- whether there was any previous treatment and what kind of treatment it had. The assumption of melanoma arises when a pigmented formation has recently appeared, increasing in size, or when accelerating the growth or changing the color of a long-existing pigmented nevus.
Physical examination
Of decisive importance is the examination of the pigmented formation. It should be done very carefully, resorting to the help of a magnifying glass if necessary. Serious difficulties occur in the recognition of melanomas arising from congenital or acquired pigmented nevi. In such cases, it is important to catch the malignancy of the nevus in a timely manner.
“Alarm signals” are signs indicating a possible malignancy of pigmented nevi. They are usually caused by the rapid proliferation of tumor cells. These include:
- an increase in size, compaction, bulging of one of the areas or a uniform growth of a pigmented formation above the skin surface;
- strengthening, and occasionally weakening of the pigmentation of the nevus;
- bleeding, cracking or superficial ulceration with crusting;
- redness, pigmented or non-pigmented strands, infiltrated tissues around the nevus;
- the appearance of itching, burning;
- formation of satellites, enlargement of lymph nodes.
Specialists distinguish five main signs of melanoma under the name "ACORD of melanoma". This name is formed capital letters 5 main signs:
BUT - Asymmetry. You can draw an axis of symmetry through a “good” mole, but not through a tumor. In specialized clinics, there is a special apparatus that allows you to evaluate a mole along 12 axes.
TO - edge. In a mole, the edges are even, in melanoma - jagged or scalloped.
O - Coloring. If the mole has changed color or is not uniform in color, this is a bad sign.
R - The size. The larger the mole, the higher the likelihood of its rebirth. The size of 6 mm is considered critical, but there are also small melanomas with a diameter of 1 mm.
D - Dynamics. This refers to any external changes: the growth of a mole, the appearance of crusts on it, cracks, inflammation, peeling, bleeding, or the sudden disappearance of a mole.
It should be a rule: any nevus that protrudes above the surface, has changed color, becomes weepy, bleeds, or causes unpleasant subjective sensations, is suspected of melanoma. Patients with such nevi need to consult a specialist - an oncologist.
Special examination methods
Examination of patients with suspected melanoma is usually performed on an outpatient basis. From general clinical trials a complete blood count is performed, in which an increase in ESR is sometimes found, and an overview chest x-ray, which is necessary to detect possible metastases to the lungs. Special research methods used to diagnose melanoma are radioisotope diagnostics, thermography, the Yaksch reaction, cytological and histological examination.
Radioisotope diagnostics. As an isotope, radioactive phosphorus (32P) is used, which is a source of radiation. Disubstituted sodium phosphate labeled with radioactive phosphorus is dissolved in 30 ml of water and given to the patient by mouth. Using special probes, the level of isotope accumulation in the pigment formation and the symmetrical point of the opposite side is examined 2, 24 and 48 hours after taking the drug. Phosphorus is more easily included in tissues whose cells are in a state of active division. Therefore, melanomas accumulate it in an amount 3-4 times greater than healthy skin. Excessive accumulation of the isotope is also observed in hematomas, pigmented nevi and other benign neoplasms. This reduces the diagnostic value of a technically simple and safe method.
thermography finds wide application in the recognition of melanoma. The intensification of metabolic processes in melanoma is accompanied by an increase in local temperature and the appearance of the so-called hot focus, which has the appearance of a bright spot on the thermogram.
Yaksh reaction. With melanomas, the content of colorless intermediate products of melanin synthesis - melanogens, which are excreted in the urine (melanuria) increases. Under the influence of oxygen, they are oxidized, turning into melanin, and the urine becomes dark in color. "Spontaneous" melanuria is rare in the early stages. It is usually observed in disseminated advanced tumors. Even more common is "radiation" melanuria - the excretion of melanogens in the urine in the process radiation treatment. In the production of the reaction, a 5% solution of ferric chloride is used as an oxidizing agent. A solution in an amount of 0.5 ml is added in drops to a test tube filled 3/4 with warm, freshly collected urine. With a positive reaction, a gray or dark gray cloud appears in the urine, slowly settling to the bottom of the test tube. The success of a reaction depends on meticulous execution technical rules. Within 3 days before the study, it is forbidden to take salicylates, tannin and their derivatives, canned food is excluded from the diet (contain salicylic acid) and wine (contains tannin). The tube must be thoroughly cleaned and viewed against a white background under natural light in the first minutes after the reagent is injected.
Morphological study allows you to establish an accurate diagnosis, but is rarely used in clinical practice due to the risk of tumor dissemination. Material for cytological examination is easy to obtain only with decaying ulcerated neoplasms. It is enough to attach a glass slide to the weeping area or very carefully scrape from the surface.
Tumor puncture, suspicious of melanoma, is permissible only with exophytic formation, if all other diagnostic possibilities have been exhausted. A prerequisite is an urgent cytological examination of the punctate. Puncture is contraindicated in case of rapid growth of a pigmented neoplasm and severe inflammatory infiltration. It is not done in the absence of an exophytic component and the small size of the tumor. The puncture is performed after a thorough examination of the patient for the possibility of surgery under anesthesia. The puncture technique for suspected melanoma has its own characteristics. The skin is treated with alcohol. A thin needle is directed parallel to the surface so that its end enters the epidermal layer without damaging the dermis. No additional needle movements can be done. When confirming the diagnosis, a radical operation should be performed as soon as possible, preferably in 20-30 minutes, but not more than 1 day after the puncture. In exceptional cases, if it is impossible to perform a radical operation within this period, radiation treatment should be started immediately.
Puncture of lymph nodes produce rarely, if otherwise it is impossible to establish the nature of the pigment formation. It is indisputable that the puncture of the lymph nodes affected by melanoma is dangerous, but its harm is not too noticeable, since the dissemination of the process has already begun.
Biopsy of pigmented lesions performed when it is impossible to establish a diagnosis in another way. A biopsy is performed only by completely removing the neoplasm. Partial excision of a tumor suspicious of melanoma is unacceptable. The biopsy is always performed under anesthesia. The neoplasm is excised, retreating 1.0-1.5 cm from visible borders. Perform urgent histological and cytological studies. When melanoma is detected, a radical operation is immediately performed, the volume of which depends on the location of the tumor.
Melanoma treatment
Treatment of melanomas is a difficult task due to rapid, early onset dissemination. It should be done only in a specialized institution.
Treatment of the primary focus
The most common method is surgical excision of the tumor; combined treatment, radiation and complex, is used somewhat less often.
Surgical treatment is indicated for melanoma stages I and II. The operation must be performed under anesthesia. A scalpel or an electroknife is widely excised skin with a tumor. From the visible edge should be retreated by at least 5 cm, and in the direction of the lymph outflow even by 7-8 cm or more. For cosmetic reasons, this cannot be done on the face. Facial melanoma usually has to be excised only 3 cm from the edge of the tumor.
The skin flap must be removed deeply. Most oncologists consider it mandatory to remove not only the skin and subcutaneous tissue, but also the underlying fascia. Removal of the fascia itself is controversial and is not recognized by some authors.
An extensive defect after excision of melanoma cannot be closed without skin grafting. On the trunk and in the proximal limbs, the defect is closed by moving local tissues. Free skin grafting should be applied on the extremities. Conventionally, it is believed that if the defect after removal of melanoma was successfully sewn up without resorting to skin grafting, then the operation was not done radically enough. In the case of melanoma located on the fingers of the hands or feet, amputation or disarticulation of the fingers is performed. At other localizations of the tumor, amputation is undesirable.
During the operation, it is necessary to strictly observe the rules of ablastics. For this purpose, the tumor is closed with a napkin soaked in iodine, stitching it to the skin within the limits of the removed preparation. In order to avoid dissemination, they try not to injure the melanoma and surrounding tissues, do not touch the tumor with fingers and instruments.
There is also a surgical intervention under the control of a microscope to increase the effectiveness of operations for skin tumors - Mohs surgery (Frederick Mohs).
Treatment of metastases in the lymph nodes
In the past, there was an attitude that regional lymph nodes in melanoma should be removed regardless of the presence of metastases. The rationale was the frequent (25-30%) detection of malignant neoplasm cells in non-palpable lymph nodes. Randomized trials have shown that prophylactic removal of regional lymph nodes does not improve long-term outcomes. Currently, lymphadenectomy is performed only in the presence of palpable metastases in the lymph nodes. As a rule, it is not performed for prophylactic purposes, but some authors resort to lymphadenectomy with deep germination of melanoma into the dermis (levels 4–5 of invasion).
Indications for regional lymphadenectomy in primary skin melanoma: table
Radiation treatment
Despite the low sensitivity of melanomas to ionizing radiation, radiation therapy as an independent treatment used to be widely used. Close-focus X-ray therapy was performed at 3–5 Gy with a total dose of up to 120–200 Gy. A wide field was irradiated, covering the skin 4–5 cm outside the tumor. Under the influence of irradiation in melanoma, even at a dose of 100 Gy, more or less deep cell damage occurred. However, without histological confirmation of the diagnosis, there was no certainty that the melanoma, and not the pigment nevus, was subjected to irradiation. Because of this, radiation therapy was no longer used as an independent method of treatment.
Combined treatment
It is used in the presence of a large exophytic component, very rapid growth or ulceration of melanoma, the appearance of satellites, and also when the tumor is located in an area where the possibility of wide excision is limited (face, palms, soles). Treatment begins with close-focus X-ray therapy with a single dose of 5 Gy. Irradiation is carried out daily 5 times a week. The total dose ranges from 60 to 120 Gy. Surgical intervention is performed after the inflammatory reaction subsides.
Chemotherapy
Melanoma is insensitive to chemotherapy. Nonetheless, medications widely used in disseminated forms, and in combination with surgery they are sometimes used for localized tumors and local relapses located on the extremities. In such cases, chemotherapy is carried out by intra-arterial perfusion, after which surgery is performed. The operation is performed immediately after perfusion or after a few days.
In disseminated tumors, imidazolecarboxamide (DTIC) is most effective, with the help of which it is possible to obtain clinical remission in 20-30% of patients. Less effective are nitrosourea, procarbazine, dactinomycin, etc. The effectiveness of drug treatment can be increased by using a combination of chemotherapy drugs. One of these combinations, containing methylnitrosourea (MNM), vincristine, and dactinomycin, has become widespread and is as effective as imidazolecarboxamide. Also used drugs such as dacarbazine (DTIC), carmustine (BCNU), lomustine (CCNU), cisplatin, tamoxifen, cyclophosphamide, etc.
Immunotherapy
Immunotherapy has sometimes been used in recent years to treat relapses and skin metastases of melanoma. It is often used in combination with chemotherapy treatment.
Usually use BCG vaccine, which is injected directly into the tumor nodes or into the skin next to the neoplasm. Such treatment in some patients leads to resorption of the nodes, but is often accompanied by a general reaction, which prevents the widespread use of immunotherapy in clinical practice.
Interferon-alpha (IFN-A), interleukin-2 (IL-2) and granulocyte-macrophage colony stimulating factor (GM-CSF) are also used. A study by the Eastern Cooperative Oncology Group (ECOG) showed that the use of interferon-alpha-2b at maximum tolerated doses provides a significant increase in disease-free period and overall survival compared with no adjuvant therapy. One of the latest developments is the treatment of melanoma with the drug Yerva (Ipilimumab).
Ipilimumab (Ipilimumab, MDX-010, MDX-101) is a melanoma drug approved in March 2011 by the FDA food products and drugs (FDA) for the treatment of advanced melanoma under the market name Yervoy. Yervoy was developed by the pharmaceutical company Bristol-Myers Squibb and is a monoclonal antibody that activates the human immune system. Yervoy is also supposed to be used to treat individual forms lung cancer and prostate cancer. Mechanism of action: ipilimumab is a human antibody that binds the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antigen, a cytotoxic T-lymphocyte molecule that probably plays an important role in the regulation of natural immune responses.
In addition to interferon-alpha (IFN-A) therapy for the treatment of melanoma, virotherapy is used - treatment of ECHO 7 with a virus-containing drug Rigvir, which is registered for the prevention of metastases and relapses of melanoma, as well as for local therapy of skin and subcutaneous metastases.
Treatment outcomes (prognosis)
Five-year recovery is observed on average in 50-65% of patients. Relatively favorable results are associated with the fact that in the majority (80-85%) of patients the tumor is recognized in stage I. The prognosis is much worse for melanoma in the II and subsequent stages, especially with the defeat of the lymph nodes.
In the absence of lymph node metastases, the thickness of the tumor and the degree of skin invasion are of decisive prognostic value. In addition, the gender of the diseased, the presence of ulceration, and the localization of the tumor are important. Other things being equal, the long-term results of treatment in women are better than in men. Melanomas of the extremities (with the exception of the subungual) proceed more favorably than melanomas of the trunk.
Clinical examination of the cured is carried out according to general rules. During control examinations, the skin, lymph nodes, liver are examined, a blood test is performed and x-ray examination lungs.
photographic materials
Remember
- Melanoma is usually a dark-colored spot or tumor of a rounded shape, elastic consistency with a smooth or bumpy surface.
- Characteristic features of melanoma are dark color, shiny surface and the tendency of the tumor to disintegrate.
- Suspicion of melanoma arises when an increasing pigmented formation appears or with an accelerated growth of a pre-existing one.
- Nevi that are discolored, weepy, bleeding, or itchy, burning, pain.
- A puncture for suspected melanoma is done in exceptional cases, with strict adherence to technical rules and mandatory urgent histological examination.
As for the clinical classifications that are used in the work of modern specialists, there are a lot of them, but below are the main types of melanomas.
private views
Spindle cell melanoma
Spindle cell melanoma is a type of skin cancer that histologically looks like cells with spindle-shaped nuclei, they are elongated, polymorphic and hyperchromic. They are arranged in bundles. Polymorphism is not very pronounced, however, granularity of the cytoplasm is observed. By the presence of pigment inside the cells, this type of tumor is distinguished from neuromas or sarcomas. The following types of spindle cell tumors are distinguished:
- Low-pigmented, with a soft texture, pink or light brown.
- Dense, low-pigmented.
- Pigmented with peeling.
- Widespread small tumors, light brown in color.
The prognosis is relatively favorable, because in nine out of ten cases there is a complete recovery without the development of damage to secondary organs or relapses. As a therapeutic tactic, a course of palliative chemotherapy and diathermic removal of the tumor are used.
Epithelioid cell melanoma
Epithelioid cell melanoma is a separate type of skin cancer characterized by a low degree of cell differentiation and a very aggressive course. Development begins with the formation of plaque-like seals in the thickness of the skin. Histologically, the cells show enlarged brightly colored round nuclei.
This type of melanoma is quite difficult to diagnose. Most often, the disease affects women after thirty to fifty years. The cause is usually frequent trauma or exposure to ultraviolet rays. The selection of treatment is carried out by a specialist, the prognosis is rather unfavorable, which is explained by the invasive course and frequent metastasis.
Disseminated melanoma
Disseminated melanoma is an aggressive tumor that has invasive growth and a long course without symptoms, up to the appearance of metastases. A feature is also the lack of response to chemotherapy. The most common location for disseminated melanoma is the skin of the trunk or back. The survival rate of patients, even with the use of complex treatment, is no more than five percent over five years.
Superficial spreading melanoma
Superficially spreading melanoma is one of the most common pathologies that is most often diagnosed in young people. The lesion usually develops on the skin of the trunk or legs. In the early stages, it looks like a focus of hyperpigmentation of the skin, with clear boundaries and slightly raised above the level of the skin.
Superficial melanoma reaches a fairly large size and its surface lends itself to destructive regression. It is against this background that the defeat of other organs with metastases and the appearance of secondary symptoms develop. The diagnosis of superficial melanoma is made on the basis of a dermatoscopic examination, the identification of tumor markers, and histology.
Lentiginous melanoma
It is also a rare type of cancer. If we turn to the statistics, then this thesis is supported by the fact that it is diagnosed in no more than five percent of cases of development of all primary melanocytes. Lentiginous melanoma usually grows on covered areas of the skin, such as the palms of the hands and feet.
Photo of a nail affected by melanoma
Sometimes, it is able to develop on the nail plates of the hands or feet. Lentiginous melanoma, or acral melanoma, is distinguished by its development on initially intact skin, but the growth rate is high enough, which leads to rapid metastasis. Because of this, the prognosis is quite unfavorable.
Pigmentary melanoma
Usually this type of skin cancer develops as a result of malignant degeneration of nevi. The development of such a result is associated with trauma, exposure to direct sunlight, as well as during hormonal changes during puberty or during pregnancy.
Melanoma of the anal canal
The tumor is usually located in the anorectal junction. Macroscopically, they are difficult to distinguish from inflammatory processes in the large intestine or from adenocarcinoma. Most often, there is an fusion of the tumor with hemorrhoids, as a result of which its thrombosis and complications in the form of bleeding develop. Melanoma of the rectum is quite rare and accounts for only a quarter of a percent of all malignant lesions of the large intestine.
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