Is melanoma curable and can it be completely cured? Melanoma on the face. Nodular or nodular melanoma

Melanoma is a dangerous disease that is much easier to prevent than to cure. Today we want to talk about the signs of melanoma, symptoms of the disease and how it develops, so that every person has an idea about it and knows how to avoid this terrible disease.

Skin melanoma is a malignant tumor, a disease that can occur in any person at any age. A common type of skin cancer that arises from melanocytes in normal skin and pigmented nevi. The development of melanoma occurs quite quickly, and soon it can affect not only certain areas of the skin and spread over the surface, but also affect bones and organs.

Melanoma is much less common than skin cancer, about 10 times, and accounts for about 1% of the total number of malignant neoplasms.

The incidence increases sharply between the ages of 30 and 40; melanoma most often affects women, but it can also occur in children of any gender.

Causes of occurrence

Most often, a fertile background for the development of melanoma is congenital pigment spots, called nevi, which are often injured, especially when located on exposed parts of the body, back, forearms or feet. A huge number of people have these nevi, more than 90%. There are borderline or epidermal-dermal nevi, intradermal nevi and mixed ones. The most dangerous are borderline nevi (you can read more about them on our website in a special section).

Melanomas that develop against the background of age spots acquired type. They can be found in humans even in adulthood. The main risk factors for melanoma are skin trauma, increased radiation consumption, hormonal surges and changes in the body, genetic predisposition to the disease, Dubreuil's melanosis and xeroderma pigmentosum.

(load position melanoma)

Symptoms of the disease

Every person can notice the symptoms of melanoma; the main thing is not to attribute them to improper behavior of the body and not to forget about the danger of the disease. By correctly understanding the signs of melanoma, you can avoid complications of the disease. So, the first signs indicating the degeneration of pigmented nevi into malignant ones:

• obvious compaction, increase in size and change in shape, swelling of any area or gradual but stable growth of a tumor above the surface of the skin;
• increased pigmentation of the nevus, in some cases, weakening of pigmentation;
• external changes in the surface of the neoplasm - cracking, crusting or ulceration, bleeding;
• the appearance of unusual itching, burning, discomfort;
• enlarged lymph nodes, the appearance of formation satellites;
• redness, deep-pigmented or pigmented cords, the appearance of infiltrated tissues surrounded by a nevus.

In other words, any noticeable and tangible change in the nevus is a prognosis for melanoma. Experts recommend that if the size of the nevus, its shape, or the number of nevi changes, or if discomfort or bleeding of the nevus occurs, immediately contact qualified doctors who will begin treatment in a timely manner.

Localization, distribution, growth

Melanoma, unlike skin cancer, does not spread primarily to the face. In more than 50% of patients, the disease occurs on the lower extremities, slightly less often on the torso, approximately 20-30%, upper limbs, about 10-15%, and only in 15-20% of cases in the neck and head area.

The spread of melanoma and its growth occur due to tissue germination, hematogenous and lymphogenous metastasis.

Melanoma grows in three directions, above the surface of the skin, deep into the skin and along its surface, successively affecting all layers of the skin, as well as the tissues under the skin. The deeper the tumor has grown, the worse the doctors’ prognosis may be.

Metastasis

Melanoma skin cancer is characterized by very early and rapid metastasis. Melanoma metastases most often affect regional lymph nodes. Metastasis to distant lymph nodes is much less common.

Basically, melanoma metastases affect the patient’s skin. They look like numerous black or black rashes that rise above the level of the skin. Brown. Hematogenous metastases can occur in any organ, but most often the human adrenal glands, liver, lungs and brain are affected.

Clinical characteristics

Initially, the disease is a dark-colored spot that rises slightly above the surface of the skin. During its growth, melanoma takes the form of an exophytic tumor, which in the future may ulcerate. What melanoma looks like can be determined by three characteristic characteristics diseases: tendency to decay, shiny surface of the neoplasm and dark color. These features are caused by the following processes: pigment accumulation, disease damage to the epidermal layer, as well as the fragility of the neoplasm.

IN in this case Some questions need to be clarified:

• have you had any previous treatment? skin diseases what its character was, what exactly it related to and what results it had;
• Are these changes associated with prolonged exposure to the sun and increased consumption of ultraviolet radiation by the skin, or with accidental injuries to the skin;
• what type of neoplasm was at the moment when it was first noticed, what modifications occurred to it and over what period of time;
• whether the neoplasm is acquired or congenital.

Treatment

Any change in the nevus—its bleeding, change in shape or size, color, etc.—requires immediate medical intervention. Most often, this is surgical intervention. It is much preferable to immediately take radical measures to remove a dangerous nevus. rather than wait for it to degenerate into a malignant tumor.

In medical practice, there are two methods of treating melanoma - surgical method and combined method. The combined method of treatment is the most justified, since after timely irradiation the tumor is removed under more ablastic conditions. Initially, at the first stage of treatment, close-focus radiotherapy is used, and after that, even before the reaction appears, a few days after irradiation, or after it subsides, a wide surgical excision of the tumor is performed, which covers up to four centimeters of healthy skin in the area affected by the tumor , as well as the underlying fascia and subcutaneous tissue. The resulting skin defect is sutured with a thin suture or covered with skin grafting.

At the moment, the most effective treatment for melanoma is treatment in Israel (), since it is there that there are specialists with sufficient medical experience.

Malignant melanoma quickly metastasizes to nearby lymph nodes. For this reason, when they increase in regional areas (inguinal-femoral region, axillary fossa, neck), they must be removed as soon as possible. If the patient has suspicious lymph nodes, preliminary irradiation is performed.

IN Lately Having discovered malignant melanoma in a person, doctors are increasingly using complex treatment of the disease, supplementing radiation and surgical methods with chemotherapy.

Due to the fact that surgery for melanoma affects only the superficial layers of the body, special preparation is not required. After the operation, patients comply with the doctor’s prescriptions - bed rest for the prescribed period and special anti-inflammatory therapy.

Relapse of melanoma is a direct consequence of non-radical actions. In such cases, distant metastases are often detected. They may be detected with relapse or even before it.

Chemotherapy treatment is used in the case of a widespread form of the disease, in the presence of distant metastases. For treatment, various combinations of drugs against tumors are used, and regression of tumors is observed in approximately 20-40% of patients.

Stages and prognosis

Any treatment for the disease and its results directly depend on the stage of melanoma at which it was detected. There are four stages of melanoma:

• Stage I - early melanoma. Treatment for melanoma involves local excision of the tumor within normal, healthy tissue. The total amount of healthy skin that must be removed depends on the depth of disease penetration. Removing lymph nodes near the melanoma does not increase the survival rate of people with stage I melanoma;
• Stage II . There may be a suspicion of damage to nearby lymph nodes. In this case, a biopsy of one of them is performed and, if it is affected, all nearby lymph nodes are removed. At this stage it is possible additional treatment drugs that reduce the likelihood of relapse. Some doctors recommend routine removal of lymph nodes in the area of ​​the tumor, although the benefits of this method have not yet been proven;
• Stage III . At this stage, the primary melanoma is removed, as well as all nearby lymph nodes. Appointed to such a case Immunotherapy may delay relapse of the disease. If the patient has several tumors, all of them must be removed. If this is not possible, special drugs are prescribed that are injected directly into the tumor. The optimal treatment method for patients at this stage has not yet been developed, although chemotherapy, radiation therapy and immunotherapy are possible. Quite often, these treatment methods are combined into a single complex;
• Stage IV . At this stage, melanoma patients cannot be completely cured. By using surgical operations remove large tumors that cause extremely unpleasant symptoms. It is extremely rare that metastases are removed from organs, but this directly depends on their location and symptoms. Chemotherapy and immunotherapy are often used in this case. Forecasts at this stage of the disease are extremely disappointing and on average amount to up to six months of life for people who develop melanoma and reach this stage. In rare cases, people diagnosed with stage 4 melanoma live several more years.

Types of melanoma

In fact, there are a considerable number of melanomas, including blood melanoma, nail melanoma, lung melanoma, choroidal melanoma, non-pigmented melanoma and others, which develop over time in different parts of the human body due to the course of the disease and metastases, but in medicine the following are distinguished: main types of melanomas:

• Superficial melanoma. This is the most common type of disease that develops from a nevus. This type characterized by slow growth over several years;
• Nodular melanoma. The next most common type of disease, which appears as a special, loose nodule on the surface of the skin, which is prone to ulceration. Grows quite quickly;
• Peripheral lentigo. A disease that is not at all typical for people of the white race. The danger of the disease lies in its frequent development on the sole, where the growth and development of melanoma is poorly visible;
• Lentigo maligna. A disease that develops in older people, the location and development of melanoma is the face.

It can be noted that melanoma cancer is a very dangerous disease and the most important thing is timely diagnosis of melanoma. It will help identify the disease through examination, examination by a doctor and laboratory tests that will accurately confirm the presence or absence of the disease. On early stages Treatment of skin melanoma is relatively simple and quite effective; the survival rate of people who seek help on time is about 95%, this is a very good result. But if you delay in solving the problem, the consequences will be not only terrible, but in the full sense of the word, irreversible. We recommend that you read the material about

Melanoma is a malignant tumor that develops from melanocytes. The tumor most often affects the skin, less often the retina, brain, and mucous membranes. The most common degeneration of moles into melanoma (70% of patients).

This disease is the most aggressive of all malignant tumors, growing at lightning speed through several layers of skin and spreading to other organs. Therefore, it is very important to diagnose melanoma as early as possible. If a mole (pigment spot) begins to grow quickly, change shape or color, or become inflamed, this is a reason to urgently consult an oncologist. Pigmentless melanoma is also common.

The tumor can also affect the retina of the eye, and the symptoms are expressed as follows: a decrease in visual acuity, an increase in its size, the appearance of ulcerations, bleeding, and nodular formations. Ocular melanoma occurs in 5-7% of cases of all pigment pathologies. Often, when examining an organ, a small melanoma is mistaken for a pigment spot.

Melanoma - treatment of the disease

The method of combating the disease depends on its stage of development. If melanoma is diagnosed, treatment is prescribed as early as possible.

Stage I: At this stage, the tumor does not extend beyond the epidermis and is treated by surgical excision.

Stage II. At this stage of the disease, a certain amount of healthy skin is simultaneously removed along with the tumor. If the doctor suspects damage to the lymph nodes, a biopsy is performed. If the test result is positive, all lymph nodes in the area of ​​melanoma are removed. Additional medications (alpha interferon or other drugs) may be prescribed.

Stage III. Characterized by damage to the lymph nodes at the time of diagnosis. Surgical treatment of melanoma is performed with lymph node dissection. Interferon therapy can delay relapse. All foci of the disease are removed (if the patient is diagnosed with several melanomas). If it is impossible to use the surgical method, injection of the BCG vaccine or interleukin-2 into the lesion is used. If melanoma is present on a limb, isolated perfusion is performed. Radiation therapy, chemotherapy and immunotherapy are also used on the affected area.

Stage IV. Melanoma, the treatment of which is no longer limited to surgical methods, has metastasized to distant lymph nodes or organs. Complete cure at this stage it is very difficult. With the help of surgery, it is possible to remove large tumor foci. Immunotherapy or chemotherapy are also prescribed.

Chemotherapy for patients with this stage of melanoma is ineffective and short-term. The most commonly prescribed drugs are dacarbazine and temozolomide.

Immunotherapy involves the use of interferon, interleukin-2, ipilimumab and allows the patient to prolong treatment at this stage.

Some patients, even at this stage of the disease, may be well responsive to treatment, which can increase life expectancy.

Traditional methods for melanoma

If melanoma is diagnosed, treatment may also include the use of traditional medicine (with prior consultation with your doctor).

For example, in the treatment of this disease, the use of aconite tincture is effective. When treating with this plant, one must not forget about its toxicity. Most often, the maximum dosage of this drug is individual and depends on the general well-being of the patient.

Very promising folk remedy products from the processing of birch bark, as well as various collections of herbs (for example, hyssop, coriander fruits) are recognized for the treatment of melanomas. However, such remedies in no way replace full treatment by an oncologist!

Which develops from pigment cells (melanocytes) that produce melanin (a natural pigment or dye that determines the color of the skin, hair and eyes).

Statistics

Moreover, the increase in the incidence of melanoma in Russia over the past 10 years has amounted to 38%.

It is noteworthy that of all skin cancers, only 4% are melanoma, but in 73% of cases it quickly progresses. fatal outcome. Therefore, melanoma is called the “queen” of tumors.

By location, melanoma in 50% of cases occurs on the legs, 10-15% on the arms, 20-30% on the torso, 15-20% on the face and neck. Moreover, in 50-80% of patients, melanoma forms at the site of moles.

In 86% of cases, the development of melanoma is associated with exposure to ultraviolet radiation (sun or tanning beds). Moreover, the risk of melanoma is 75% higher in people who began tanning in a solarium before the age of 35.

• In 1960, Peruvian Incas mummies were examined and found to have signs of melanoma. Using radiocarbon dating (used to determine the age of biological remains), it was proven that the age of the mummies was about 2400 years.
• The first mention of melanoma is found in the works of John Hunter (Scottish surgeon). But not knowing what he was dealing with, in 1787 he described melanoma as “cancerous fungal growths.”
• However, it was not until 1804 that Rene Laennec (a French physician and anatomist) defined and described melanoma as a disease.
• American scientists have developed an interesting and unique technique to detect melanoma tumor cells. Researchers say that when exposed to laser radiation, melanoma cells emit ultrasonic vibrations, which allows them to be detected in the blood long before they take root in other organs and systems.

Skin structure

• Epidermis- the outer layer of the skin, which has five rows of cells: basal (lower), spinous, granular, shiny and horny. Normally, melanocytes are found only in the epidermis.
• Dermis- the skin itself, consisting of two words: reticular and papillary. They contain nerve endings, lymphatic and blood vessels, hair follicles.
• Subcutaneous fat comprises connective tissue and fat cells, which are permeated with blood vessels and lymphatic vessels, as well as nerve endings.

What are melanocytes?

However, melanocytes are also located in the iris (contains pigment cells that determine eye color), the brain (substantia nigra) and in the internal organs.

Melanocytes have processes that allow them to move through the epidermis. Also, through the processes, the coloring pymentum is transmitted to other cells of the epidermis - this is how color is imparted to the skin and hair. Whereas when melanocytes degenerate into cancer cells, the processes disappear.

It is noteworthy that there are several varieties of melanin: black, brown and yellow. Moreover, the amount of pigment produced depends on the race.

In addition, internal and/or external factors can affect melanin synthesis (reduce or increase): during pregnancy, when taking certain medicines(for example, glucocorticoids) and others.

The value of melanin for humans

• Determines the color of eyes, nipples, hair and skin, which depends on the distribution and combination different types pigments.
• Absorbs ultraviolet rays (UV rays), protecting the body from their harmful influences. Moreover, under the influence of UV rays, the production of melanin increases - a protective reaction. Externally it appears as a tan.
• Acts as an antioxidant. What's happening? Free radicals (formed under the influence of UV rays) are unstable molecules that take the missing electron from full-fledged cell molecules, which then themselves become unstable - a chain reaction. Whereas melanin gives the unstable molecule the missing electron (the smallest particle), breaking the chain reaction.

Ultraviolet radiation reaching the earth's surface is divided into two main types:

• UVB rays are short waves that penetrate shallowly into the skin and therefore cause sunburn. In the distant future, they can lead to the development of skin cancer.
• UVA rays are long waves that can penetrate deeply into the skin without causing burns or pain. Therefore, a person, without experiencing pain, can receive a high dose of radiation that exceeds the skin's natural protective ability to tan. Then how exactly is UVA rays to blame for the development of melanoma, since in large doses they damage pigment cells.

Causes and risk factors for melanoma

Cause- the appearance of a defect in the DNA molecule of a pigment cell, which ensures the storage and transmission of genetic information from generation to generation. Therefore, if, under the influence of certain factors, a “breakdown” occurs in the melanocyte, it mutates (changes).

Moreover, melanoma can develop in any person, regardless of skin color and race. However, some people are more susceptible to developing this disease.

Risk factors

Mechanism of melanoma formation

What's happening?

UV rays cause “breakage” in the melanocyte DNA molecule, so it mutates and begins to multiply intensively.

However, in The protective mechanism works normally: MC1R protein is present in melanocytes. It promotes the production of melanin by pigment cells, and is also involved in the restoration of the DNA molecule of melanocytes damaged by UV rays.

How does melanoma form?

Fair-haired people have a genetic defect in the MC1R protein. Therefore, pigment cells do not produce enough melanin.

In addition, under the influence of UV rays, a defect occurs in the MC1R protein itself. As a result, it no longer transmits information to the cell about the need to repair damaged DNA, leading to the development of mutations.

However, the question arises: why can melanoma develop in areas that have never been exposed to UV rays?

Scientists have given an answer: it turns out that melanocytes have a very limited ability to repair damaged DNA by any factor. Therefore, they are often susceptible to mutation even without exposure to UV rays.

Stages of skin melanoma

However, to make it easier to understand the stages of skin melanoma, they use the systematization of two American pathologists:

• According to Clark, it is based on the penetration of the tumor into the layers of the skin
• According to Breslow - when the thickness of the tumor is measured

Types of melanomas

However, melanocytes are also present in other organs. Therefore, the tumor can also affect them: the eyes, head and spinal cord, rectum, mucous membranes, liver, adrenal tissue.

Clinical forms of melanoma

There are two phases during the course of melanoma:

• Radial growth: Melanoma grows on the surface of the skin, spreading horizontally
• Vertical growth: the tumor grows into the deeper layers of the skin

There are five most common types of skin melanoma.

Signs of skin melanoma

They differ depending on the shape of the tumor and stage of development.

Superficial spreading melanoma

Metastases occur in 35-75% of cases, so the prognosis is not very favorable.

What's happening?

In the radial growth phase on the skin there is a slightly raised pigment formation up to 1 cm in size, which has an irregular shape and unclear edges. Its color can be brown, black or blue (depending on the layer of skin in which the pigment is located), and sometimes black or grayish-pink dots (blotches) appear on it.

As the pigment formation grows, it thickens, turning into a black plaque with a shiny surface, and a clearing area appears in its middle (the pigment disappears).

In the vertical growth phase the plaque turns into a knot, the skin of which becomes thinner. Therefore, even with minor trauma (for example, friction with clothing), the node begins to bleed. Next, ulcers appear on the node, from which sanguineous discharge appears (liquid yellow color, sometimes containing blood).

Nodular melanoma

What's happening?

There is no horizontal growth stage, and in the vertical growth phase, the skin of the node becomes thinner, so even a slight injury leads to bleeding. Subsequently, ulcers form on the node, from which a yellowish liquid is released, sometimes mixed with blood (ichor).

The node itself has a dark brown or black color, and often a bluish tint. However, sometimes there is no pigment in the tumor node, so it can be pink or bright red.

Lentiginous melanoma (Hutchinson's freckle, lentigo maligna)

Melanoma is mainly located in areas of the skin that are constantly exposed to sunlight (face, neck, ears, hands).

The development of melanoma is long: it can take from 2-3 to 20-30 years. And as it grows, the pigment formation can reach 10 cm or more in diameter.

Moreover, metastases in this form of melanoma develop late. In addition, when turned on in a timely manner immune mechanisms protection, it can partially resolve spontaneously. Therefore, lentiginous melanoma is considered the most favorable form.

What's happening?

In the radial phase the boundaries of the dark brown formation become blurred and uneven, resembling a geographical map. At the same time, black inclusions appear on its surface.

In vertical phase against the background of the spot a node appears that can bleed or discharge serous fluid. The node itself is sometimes discolored, and crusts form on its surface.

Acral lentiginous melanoma

The disease develops rapidly, and metastases spread quickly. That's why
the prognosis is unfavorable.

What's happening?

In the radial phase tumor formation is a spot, the color of which on the skin can be brownish-black or reddish-brown, under the nail - bluish-red, bluish-black or purple.

In vertical phase Often ulcers appear on the surface of the tumor, and the tumor itself takes on the appearance of mushroom-shaped growths.

With subungual melanoma, the nail is destroyed, and bloody discharge appears from underneath it.

Amelanotic melanoma

That's why amelanoma is a flesh-colored or pink formation. It can be a type of nodular melanoma or the result of metastasis of any form of melanoma to the skin.

Melanoma of the eye

Symptoms depend on the location of the lesion: the iris (contains pigment cells that determine eye color), conjunctiva, lacrimal sac, eyelids.

However, there are signs that should alert you:

• One or more spots appear on the iris of the eye
• Visual acuity does not suffer for a long time, but gradually it worsens on the side of the diseased eye
• Decreases over time peripheral vision(objects located on the side are difficult to see)
• Flashes, spots or glare appear in the eyes
• Initially, there is pain in the affected eye (due to increased eye pressure), then they subside - a sign that the tumor has gone beyond the limits eyeball
• Redness (inflammation) occurs on the eyeball, and blood vessels become visible
• A dark spot may appear on the white of the eyeball

How does melanoma manifest?

In addition, changes are present both at the site of melanoma origin (the primary focus) and in other organs - with the spread of metastases.

Moreover, sometimes the primary tumor with the appearance of metastases either stops growing or undergoes reverse development. In this case, the diagnosis itself is made only after damage to other organs by metastases. Therefore, it is necessary to know about the manifestations of melanoma.

Melanoma symptoms

1. Itching, burning and tingling in the area of ​​pigment formation is due to increased cell division within it.
2. Hair loss from the surface of the nevus caused by the degeneration of melanocytes into tumor cells and destruction hair follicles.
3. Color change:
   • Increased or appearance of darker areas on pigment formation is due to the fact that the melanocyte, degenerating into a tumor cell, loses its processes. Therefore, the pigment, unable to leave the cell, accumulates.
   • Enlightenment due to the fact that the pigment cell loses its ability to produce melanin.
   Moreover, the pigment formation changes color unevenly: it becomes lighter or darker at one edge, and sometimes in the middle.
4. Increase in size speaks of increased cell division within the pigment formation.
5. The appearance of ulcers and/or cracks, bleeding or moisture is caused by because the tumor destroys normal cells skin. Therefore, the top layer bursts, exposing the lower layers of skin. As a result, at the slightest injury, the tumor “explodes” and its contents pour out. In this case, cancer cells enter healthy skin, penetrating into it.
6. The appearance of “daughter” moles or “satellites” near the main pigment formation- a sign of local metastasis of tumor cells.
7. Uneven edges and thickening of the mole- a sign of increased division of tumor cells, as well as their germination into healthy skin.
8. Disappearance of skin pattern is caused by the tumor destroying the normal skin cells that form the skin's pattern.
9. The appearance of redness around the pigment formation in the form of a corolla - inflammation, indicating that the immune system has recognized tumor cells. Therefore, she sent special substances (interleukins, interferons and others) to the tumor site, which are designed to fight cancer cells.
10. Signs of eye damage: dark spots appear on the iris of the eye, visual disturbances and signs of inflammation (redness), there is pain in the affected eye.

Diagnosis of melanomas

• Examination by a doctor (oncologist or dermatologist)
• Study of pigment formation using optical instruments without damaging the skin
• Sampling from a suspicious area of ​​tissue, followed by its examination under a microscope

Examination by a doctor

There are criteria by which a benign tumor can be preliminarily distinguished from melanoma. Moreover, knowing them, everyone can check their skin on their own.

What are the signs of malignant transformation?

Asymmetry- when the pigment formation is asymmetrical. That is, if you draw an imaginary line through its middle, both halves are different. And when a mole is benign, then both halves are the same.

Border. In melanoma, the edges of the pigment formation or mole have an irregular and sometimes jagged shape. Whereas benign formations have clear edges.

Color moles or formations that degenerate into a malignant tumor are heterogeneous, having several different shades. Whereas normal moles are one color but may include lighter or darker shades of the same color.

Diameter for a normal mole or birthmark - about 6 mm (the size of an eraser at the end of a pencil). All other moles must be examined by a doctor. If no deviations from the norm are noted, such formations should be monitored in the future by regularly visiting a doctor.

Changes the number, boundaries and symmetry of birthmarks or moles is a sign of their degeneration into melanoma.

On a note

Melanoma does not always differ from a normal mole or birthmark in all of these ways. Just one change is enough to see a doctor.

If the formation seems suspicious to the oncologist, he will conduct necessary research.

When is a biopsy and microscopy of a pigment formation needed?

To distinguish dangerous pigmented formations on the skin from non-dangerous ones, three main research methods are used: dermatoscopy, confocal microscopy and biopsy (sampling a piece of tissue from the lesion followed by examination under a microscope).

Dermatoscopy

For this, a special instrument is used - a dermatoscope, which makes the stratum corneum of the epidermis transparent and gives a 10-fold magnification. Therefore, the doctor can carefully consider the symmetry, boundaries and heterogeneity of the pigment formation.

There are no contraindications to the procedure. However, its use is not informative in non-pigmented and nodular melanomas. Therefore, more thorough research is needed.

Confocal laser scanning microscopy (CLSM)

According to statistics, the diagnosis in 88-97% of early stages of melanoma using CLSM is made correctly.

Methodology

A series of optical sections (photographs) are taken in vertical and horizontal planes using a special installation. Then they are transferred to a computer, where they are already examined in a three-dimensional image (in 3D - when the image is transmitted in full). In this way, the condition of the layers of the skin and its cells, as well as blood vessels, is assessed.

Indications for testing

• Primary diagnosis of skin tumors: melanoma, squamous cell carcinoma and others.
• Detection of melanoma recurrence after removal. Because due to lack of pigment, the initial changes are minor.
• Dynamic monitoring of precancerous skin diseases (for example, Dubreuil's melanosis).
• Examination of facial skin when unaesthetic spots appear.

However, if we are talking about melanoma, then the final diagnosis is made only on the basis of examining a tissue sample from the lesion.

Biopsy

However, the procedure carries certain risks. Because if you incorrectly “disturb” melanoma, you can provoke its rapid growth and spread of metastases. Therefore, tissue sampling from the site of the suspected tumor is performed with precautions.

Indications for biopsy

• If all possible diagnostic methods used, but the diagnosis remains unclear.
• The pigment formation is located in areas unfavorable for removal (a large tissue defect is formed): hand and foot, head and neck.
• The patient is scheduled to undergo amputation of a leg, arm, and removal of the breast along with regional (nearby) lymph nodes.

• The patient must be fully examined.
• The procedure is carried out as close as possible to the next treatment session (surgery or chemotherapy).
• If the pigment formation has ulcers and weeping erosions, fingerprint smears are taken. To do this, apply several fat-free glass slides (glass plastic on which the taken material will be examined) to the surface of the tumor, trying to obtain several tissue samples from different areas.

Excisional biopsy - removal of the tumor focus

It is performed when the tumor is less than 1.5-2.0 cm in diameter. And it is located in places where removal will not lead to the formation of cosmetic defects.

The doctor uses a surgical knife (scalpel) to remove the melanoma, excising the skin to its full depth, including 2-4 mm of healthy skin.

Incisional biopsy - marginal excision

It is used when it is impossible to immediately close the wound: the tumor is located on the face, neck, hand or foot.

Therefore, the most suspicious part of the tumor is removed, including an area of ​​intact skin.

When the diagnosis is confirmed (regardless of the biopsy method), tissue is excised according to the depth of tumor penetration. The operation is performed on the same day or no more than one to two weeks later if the laboratory doctor finds it difficult to provide an urgent answer.

Fine-needle or puncture biopsy (obtaining a tissue sample by puncture) is not performed for primary melanoma. However, it is used when a relapse or the presence of metastases is suspected, and also for examining regional (nearby) lymph nodes.

Biopsy of sentinel lymph nodes

“Sentinel” or regional lymph nodes are located closest to the tumor, becoming a “trap” for cancer cells.

Tumor cells remain in the lymph nodes for some time. However, then, with the flow of lymph and blood, they spread throughout the body (metastases), affecting and disrupting the functioning of vital organs and tissues.

Therefore, to assess the condition and determine further treatment tactics, a tissue sample is taken from the “sentinel” lymph nodes.

Indications for biopsy

• The thickness of melanoma is from 1 to 2 mm.
• Patients over 50 years of age because they have a poor survival prognosis.
• Melanoma located on the head, neck or face because the lymph nodes are close to the tumor. Therefore, the likelihood of cancer cells spreading from the primary site is higher.
• The presence of ulcers and weeping erosions on the surface of melanoma is a sign of tumor growth into the deeper layers of the skin.

Execution method

Around the lymph nodes, a special dye with a phosphorus isotope is injected into the skin, which moves through the lymphatic vessels towards the lymph nodes, accumulating in them. Then, two hours later, lymphoscintigraphy is performed - using a special installation, an image of the lymph node is obtained.

Distinctive features of dysplastic nevus and melanoma in the radial as well as vertical growth phase

Laboratory tests to diagnose melanoma

Laboratory indicators

The content of some factors in venous blood:

• LDH (lactate dehydrogenase)- an enzyme that increases in the presence of melanoma metastases to the liver. However, this figure also increases with myocardial infarction, viral hepatitis and muscle injuries. Because it is found in almost all tissues of the body. Therefore, focusing only on the LDH level does not make a valid diagnosis.
• CD44std (melanoma marker)- a receptor located on the surface of skin cells for hyaluronate (a component of the skin that moisturizes it).

  The indicator increases when skin cells are damaged and metastases spread. Therefore, CD44std helps in the early diagnosis of melanoma and provides insight into the further prognosis of the disease.

• Protein S100 present in nervous tissue, liver and muscles. The level of its increase in the blood indicates the number and extent of organs affected by metastases. In approximately 80% of patients with unsuccessful treatment, this indicator is high. Whereas in 95% of patients in whom the treatment is effective, it decreases.
• Fibroblast growth factor (bFGF) increases during the transition of melanoma from the superficial to the vertical growth phase. This figure is especially high in late stages disease, therefore indicating a poor prognosis.
• Vascular growth factor (VEGF) speaks of increased growth of blood vessels and melanoma itself. This indicator is high in patients at stages III and IV of the disease, which indicates a poor prognosis of the disease.

Treatment of melanoma

There are surgical and conservative treatments for melanoma, which include various techniques. Moreover, their use depends on the stage of the malignant tumor and the presence of metastases.

When is surgery needed to remove skin melanoma?

The goal is to remove the tumor while capturing healthy tissue to prevent the spread of metastases.

Moreover, at stages I and II of melanoma, surgical removal often remains the only treatment method. However, patients with stage II tumors should be monitored with periodic monitoring of the condition of the “sentinel” lymph nodes.

Rules for removing melanoma

• Under general anesthesia, because local anesthesia there is a risk of tumor cells spreading (needle trauma).
• Careful treatment of healthy tissues.
• Without affecting melanoma to prevent the spread of cancer cells. Therefore, the incision on the torso is made 8 cm away from the edges of the tumor, on the extremities - 5 cm.
• Contact of the tumor with healthy cells is excluded.
• Removal is carried out with the capture of a certain area of ​​healthy tissue (wide excision) to exclude relapse. Moreover, the tumor is removed, capturing not only the surrounding skin, but also subcutaneous tissue, muscles and ligaments.
• The operation is usually performed using a surgical knife or an electric knife.
• Cryodestruction (use of liquid nitrogen) is not recommended. Because with this method it is impossible to determine the thickness of the tumor, and the tissue is not always completely removed. Therefore, cancer cells may remain.
• Before the operation, the contours of the proposed incision are marked on the skin with a dye.

More than 140 years have passed since the first removal of melanoma, but there is still no consensus on the boundaries of excision. Therefore, WHO developed criteria.

Limits of healthy tissue removal according to WHO recommendations

It is considered inappropriate to remove more healthy tissue. Since this does not affect the survival of patients, it does impair tissue restoration after surgery.

However, in practice it is difficult to adhere to such recommendations, so the decision is made by the doctor in each specific case individually.

Much also depends on the location of the tumor itself:

• On the fingers, hands and feet, amputation of fingers or part of a limb is resorted to.
• On the earlobe, it is only possible to remove the lower third of it
• On the face, neck and head, with large melanomas, they cover no more than 2 cm of healthy tissue, regardless of the thickness of the melanoma

Removal of sentinel lymph nodes

However, numerous studies have shown that prophylactic removal of sentinel lymph nodes significantly improves patient survival.

Therefore, it is advisable to perform a biopsy of the “sentinel” node, and if there are cancer cells in it, remove it.

However, unfortunately, sometimes micrometastases remain undetected. Therefore, in certain situations, prophylactic removal of regional lymph nodes is justified. Therefore, the doctor makes an individual decision.

Treatment of melanoma with drugs

• Chemotherapy: Medicines are prescribed that act on rapidly multiplying melanoma cancer cells.
• Immunotherapy: medications are used to improve the functioning of the immune system.
• Hormone therapy (Tamoxifen), which suppresses the proliferation of tumor cells. However, this approach is controversial, although there are cases of achieving remission.

At stages I and II of melanoma, surgical intervention is usually sufficient. However, only if the melanoma was removed correctly and there were no aggravating factors (for example, diseases of the immune system). In addition, immunotherapy is sometimes prescribed for stage II. Therefore, the doctor makes the decision individually in each case.

A different approach to patients who have stage III or IV melanoma: they require chemotherapy and immunotherapy.

Chemotherapy for melanoma

However, melanoma cells grow and divide rapidly, and rapidly spread throughout the body (metastases). Therefore, there is still no single developed scheme for prescribing chemotherapy for its treatment.

The most commonly used chemotherapy drugs for the treatment of melanoma are:

• Ankylation agents: Cisplastin and Dacarbazine
• Notrosourea derivatives: Fotemustine, Lomustine and Carmustine
• Vinkaalkaloids (means plant origin): Vincristine, Vinorelbine

The drugs are prescribed either alone (monotherapy) or in combination, but depending on the stage of melanoma, the presence of metastases and the depth of tumor invasion.

Moreover, Dacarbazine is considered the “gold” standard in the treatment of melanoma, since no other drug has exceeded its effectiveness. As a result, all combination treatment regimens are based on its use.

Indications for chemotherapy

• Basic blood parameters are within normal limits: hemoglobin, hematocrit, platelets, granulocytes
• Satisfactory functioning of the kidneys, liver, lungs and heart
• Absence of diseases that may interfere with chemotherapy (for example, chronic renal failure)
• Tumor involvement of sentinel lymph nodes
• Prevention of the spread of metastases
• Supplement surgical method treatment

They are divided into two groups: absolute and relative.

Absolute- when chemotherapy is not performed:

• Chronic liver and kidney diseases with pronounced violation functions (chronic renal failure, liver cirrhosis)
• Complete disruption of the outflow of bile (blockage of the bile ducts)
• Availability mental illness in the acute stage
• When it is known that chemotherapy will be ineffective
• Severe underweight (cachexia)

• Autoimmune diseases (eg, rheumatoid arthritis) and immunodeficiency conditions (eg, AIDS)
• Old age
, therefore the risk of developing infectious diseases increases significantly

Depends on the stage of the disease and the method of administration (alone or in combination).

Thus, with monotherapy for advanced melanoma (lytic lesions or the presence of metastases), the effectiveness (complete regression for 3 or more years) does not exceed 20-25%. With combined administration, according to various authors, the overall effectiveness ranges from 16 to 55%.

Melanoma immunotherapy

As a result, primary melanoma can regress (grow back) on its own. In this case, pronounced redness appears around the tumor (immune cells fight cancer cells), and then vitiligo (an area of ​​clearing of the skin) appears at the site of the tumor.

Therefore, immunological drugs are used to treat melanomas: Interferon-alpha, Interleukin-2, Reaferon, Ipilimumab (the latest generation drug).

Moreover, they can be used either alone or in combination with chemotherapy. Since their administration, even in late stages, improves the prognosis of the disease by 15-20%. In addition, positive results are observed in patients who have previously received chemotherapy.

The effectiveness of immunotherapy

If achieved positive result from immunotherapy, there is a high chance of a good prognosis.

Since in the first two years after treatment, 97% of patients experience a partial disappearance of signs of melanoma, and 41% experience a complete reversal of the symptoms of the disease (remission). Moreover, if remission lasts more than 30 months, the likelihood of relapse (new development of the disease) is reduced to almost zero.

However, it should be remembered that the use of immunopreparatives causes the development of a large number of complications: toxic effects on the liver and kidneys, the development of sepsis (spread of infection throughout the body) and others.

New treatments for melanoma

In Israeli clinics, Bleomycin (an antibiotic) is used. It is injected directly into tumor cells using electricity - electrochemotherapy.

According to Israeli scientists, this method of treating melanoma quickly achieves a good effect. However, time will tell how effective its long-term results will be (duration of remission, occurrence of relapses).

Radiation for melanoma

Moreover, cancer cells are more sensitive to ionizing radiation because they divide faster than healthy cells of the body.

However, ionizing radiation is not used “by eye”, since healthy cells are also damaged. Therefore, it is important to focus the beam, directing it to the tumor with millimeter precision. Only modern devices can cope with such a task.

Methodology

Apply special installations, which emit electron beams or X-rays with great energy.

At first the device makes a simple X-ray, which is displayed on the monitor screen. Then the doctor, using a manipulator, marks the tumor, indicating its boundaries and sets the radiation dose.

• Moves the patient
• Rotates the emitting head
• Adjusts the collimator curtains (a device for producing ionizing radiation) so that the tumor is in the crosshairs

Indications

• Recurrence of melanoma for irradiation of metastases
• Treatment of melanoma located in areas where it is difficult to excise the tumor (for example, the skin of the eyelid or nose)
• Treatment of eye melanoma with damage to the iris and protein membrane
• After surgery to remove lymph nodes to prevent recurrence of melanoma
• Pain relief from metastases to the brain and/or bone marrow

• Autoimmune diseases: systemic lupus erythematosus, psoriatic arthritis and others
• Severe underweight (cachexia)
• Platelets and leukocytes in the blood are sharply reduced
• Severe diseases of the kidneys, liver and lungs, accompanied by insufficient functioning (cirrhosis, renal failure and others)

• General weakness, increased irritability, headache
• Increased dryness in the oral cavity and skin, nausea, belching, loose stools
• Marked decrease in blood leukocytes and hemoglobin
• When irradiating the head and neck area - hair loss

Skin melanoma cells are insensitive to conventional doses radioactive radiation. Therefore, for a long time, radiation therapy was not used to treat melanoma.

However, it has now been proven that when used high doses ionizing radiation improves the prognosis of melanoma.

For example, for metastases to the brain, the effectiveness is 67%, bones - 50%, lymph nodes and subcutaneous tissue - 40-50%.

Whereas when radiation therapy is combined with chemotherapy, the overall effectiveness approaches 60-80% (depending on the stage of melanoma).

When treating the initial stages of eye melanoma (tumor thickness - up to 1.5 mm, diameter - up to 10 mm), the effectiveness of radiation therapy is equivalent to enucleation (removal) of the eye. That is, complete recovery occurs.

Whereas in the later stages (thickness - more than 1.5 mm, diameter - more than 10 mm), the volume of the tumor decreases by 50%.

Prognosis for melanoma

Melanoma statistics

What does melanoma look like?

Options appearance melanomas are:

• flat pigment spot;
• mushroom-shaped, and it can be located on a stalk or a wide base;
• slight protrusion;
• papillomatous growth.

Initially, the surface of melanoma is smooth and shiny, sometimes even as if mirror-like. As the disease progresses, irregularities and ulcerations appear ( small ulcers on the surface). The danger at this stage is that it begins 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 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 dense 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 directly 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 mascara.

Pigmentation may be uniform ( all melanoma is the same color) or uneven. In the second case, the tumor is more pigmented in the center and has a black rim around its circumference, typical of melanoma. Melanoma often has a variegated color, combining different shades.

A change in the color of 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, brightening. Moreover, pigmented melanomas can turn into non-pigmented melanomas and vice versa.

Nail melanoma and subungual melanoma

Types of nail melanoma are:

• melanoma growing from the skin near the nail plate;
• melanoma growing directly from the nail plate itself;
• melanoma growing from the nail.

Melanoma of the eye

Types of ocular melanoma include:

• conjunctival melanoma;
• melanoma of the century;
• choroid melanoma;
• iris melanoma.

The main treatment method is surgical removal of the melanoma.

Melanoma on the face

Melanoma on the back

Symptoms ( signs) melanoma

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

Melanoma can begin to develop either from a previous nevus or independently. In the first case, a birthmark ( mole or nevus) begins to enlarge, 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 clothing) or after prolonged exposure to the sun. However, also the process of malignancy ( malignancy) may begin spontaneously. There is a so-called malignancy rule, which includes four criteria. It is abbreviated as ABCD - an acronym 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 dissimilar from each other;
• the edges ( border) - become uneven and intermittent;
• color ( color) – the color changes, a previously light or brown mole becomes black, and its color often becomes uneven – with inclusions of red and blue;
• 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

Causes of melanoma development include:

• ultraviolet radiation;
• hormonal imbalance;
• genetic predisposition.

Studies have confirmed that skin melanoma is more likely to occur in those people who spend most of their time indoors and relax by being exposed to 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 in equally both ultraviolet radiation and ethnic factors influence. Thus, it is reliable that the tumor develops in people with fair skin. Statistics indicate a lower incidence of melanoma among people of the Black race ( despite the fact that in their epidermis the number of melanocytes is the same as in people with white skin). The main role in the pathogenesis of melanoma is played by a violation of the body's pigmentation. The consequence of this is an abnormal skin reaction to solar radiation.

Skin pigmentation disorders can be judged based on skin color, as well as hair and eye color. The level of pigmentation can also be indicated by the presence of a large number of pigment spots on the skin ( scientifically nevi) and freckles. In such people, ordinary short-term exposure to the sun is accompanied by burns. The classic patient with melanoma is the owner of a light ( sour cream colors) skin with many age spots and freckles, straw-colored hair and blue eyes. The risk of developing melanoma in red-haired people is 3 times higher than in fair-haired people.

Hormonal imbalance
Melanoma often develops during periods accompanied by hormonal changes. This may be during puberty in adolescents and menopause in women. Thus, under the influence of hormones, existing moles begin to degenerate - they increase in size, change shape and color.

Genetic predisposition
The genetic factor is also one of the main causes of melanoma development. 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, intense growth). They are characterized by malignant degeneration, that is, transition to malignant melanoma. Therefore, this syndrome is considered one of the main risk factors contributing to the development of cutaneous melanoma.

Nevus, moles and other risk factors for melanoma

Despite the fact that a nevus is a benign and often harmless formation, it is a risk factor for the development of melanoma. In people with multiple nevi, the risk of developing skin cancer increases several times. Therefore, dermatologists advise monitoring the growth and number of nevi on the skin. Particular importance is attached to injury to nevi. Thus, cases of skin melanoma occurring after injury have been described. This could be a one-time bruise, cut or simple abrasion. Nevi can be subject to chronic traumatization by clothing or shoes, which should also be taken into account.

Unfortunately, more than half of all primary skin melanomas develop against the background of nevi. This allows us to regard them as a precancerous condition. At the same time, the frequency of malignancy ( malignancy) of nevi correlates with their size. For example, with a nevus measuring more than two centimeters, the risk of developing 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 develop into malignant melanoma in 100 percent of cases. Congenital nevi occur in one percent of newborns. They differ from acquired nevi in ​​their significant size and darker color.

Signs of dysplastic nevi are:

• diameter more than half a centimeter;
• irregular 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 Dubreuil's melanosis. This syndrome is characterized by areas of skin pigmentation in middle-aged and elderly people. It is most often localized on the face, but can also develop in other areas of the body. The main signs of melanosis are uneven coloring and uneven edges. The contours of a pigment formation often resemble a geographical map. Dubreuil's melanosis is distinguished by its scale - spots can reach up to 10 centimeters in diameter. Today, melanosis and nevus are generally regarded as precancerous conditions.

Types of melanoma

The types of melanomas according to the clinical classification include:

• superficial spreading melanoma;
• nodal ( nodular) melanoma;
• lentigo melanoma;
• peripheral lentigo.

Superficial spreading melanoma

The characteristics of superficial spreading melanoma are:

• small sizes;
• irregular shape;
• uneven edges;
• polymorphic color interspersed with brown, red and bluish colors;
• often ulcerates and bleeds.

Nodal ( nodular) melanoma

Lentigo melanoma or lentigo maligna

Peripheral lentigo

Pigmented melanoma

The color of pigmented 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 uneven, which is an unfavorable sign. Thus, a previously homogeneous melanoma in the third and fourth stages becomes variegated and contains various shades. Pigmented melanoma can become non-pigmented and lose its characteristic shade.

Amelanotic melanoma

Diagnosing this type of tumor is a very difficult task. Diagnosis becomes difficult especially when there are already nevi on the skin. Main diagnostic symptom is the rapid growth and change in color of the tumor. However, the diagnosis is made on the basis of a dermoscopic examination.

Malignant melanoma

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 invasion ( germination) into neighboring organs and tissues and the formation of local metastases in them.
• Ability to metastasize- movement of tumor particles to distant organs with blood or lymph flow.
• Development of a powerful intoxication syndrome ( "cancer poisoning"). This syndrome is characteristic of the later stages of the disease and is manifested by the penetration of dead tissue of the body into the general bloodstream.
• The ability to evade the body's immunological control.
• Very low differentiation ( division) cells compared to healthy cells.
• Angiogenesis– the ability to form one’s own circulatory system. Thus, in 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

The types of melanoma classifications include:

• international classification TNM– characterizes the size of the tumor, the presence of metastases;
• 5-stage classification- common in the west;
• clinical classification- unlike previous classifications, describes only three stages.

Melanoma stages according to TNM

Initial stage of melanoma

First stage of melanoma

The characteristics of the first stage according to the clinical classification are as follows:

• single primary neoplasm;
• satellites are allowed ( accompanying 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 of melanoma

Stage three melanoma

The characteristics of stage three melanoma according to the Western classification include:

• thickness more than 4 millimeters;
• tumor growth into the subcutaneous fat layer;
• availability of satellites ( additional) tumors within 2 - 3 centimeters from the primary tumor;
• metastasis to regional lymph nodes.

Fourth stage

Melanoma in children

Causes of melanoma development in children

Symptoms of melanoma in children

Signs of melanoma in children are:

• change in color of a previous nevus or mole;
• proliferation of a previously “quiet” nevus;
• elevation of the formation above the skin;
• the appearance of cracks;
• the appearance of a burning and tingling sensation;
• formation of ulcers ( ulceration phenomenon) followed by repeated bleeding;
• hair loss on the nevus and adjacent skin.

The biological feature is resistance ( sustainability) tumors to chemotherapy and radiotherapy. Thus, despite the fact that standard chemotherapy regimens have long existed for the treatment of melanoma in adults, they are not applicable for children. Although new regimens have recently been developed for the treatment of malignant melanoma among children, despite this, the main treatment method has been and remains surgical.

Prognosis for melanoma

Metastases in melanoma to the brain and lymph nodes

No matter where melanoma is located, as it progresses, it always metastasizes to the lymph nodes. This happens already at the second stage, when melanoma begins to ulcerate and becomes loose, as a result of which tumor cells enter the lymphatic capillaries ( which are present everywhere). From the capillaries, along with the fluid, cancer cells enter the nearest lymph nodes. The cells settle there and begin to multiply, forming a secondary focus in the lymph node. For this period tumor process is temporarily suspended. However, the lymph node damaged by cancer cells continues to grow to a certain stage. Then it becomes loose again, and tumor particles from it reach another, more distant lymph node through the lymphatic capillaries. The farther from the primary focus, the more advanced the disease is considered.

Melanoma most often affects the cervical, axillary and intrathoracic nodes. Symptoms of the lesion are polymorphic ( varied) and depends on the number of affected nodes and the degree of compression.

Metastases in the cervical lymph nodes
In a healthy person, this group of lymph nodes is not visible or palpable externally. 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 over them is not changed, which is an important diagnostic sign. To the touch they are dense, motionless, and often painless. If deep cervical nodes are affected by metastases, they are not visually marked in any way. At the same time, an asymmetric thickening of the neck appears.

Metastases in the axillary lymph nodes
Patients with metastases in the axillary lymph nodes complain of a sensation of a foreign body in the armpit, as if something is bothering them. IN axillary area lymph nodes are located along the vessels and nerves. If the lymph node is located near a nerve, pain, numbness in the arm, or tingling of the skin may occur. When blood vessels are compressed, swelling of the hand develops.

Metastases in intrathoracic lymph nodes
In the cavity chest located a large number of lymph nodes, which are called intrathoracic. The symptoms of damage to these lymph nodes depend on their location and size.

Symptoms of metastases in the intrathoracic lymph nodes include:

• persistent cough;
• difficulty swallowing;
• cardiac rhythm and conduction disturbances;
• hoarseness of voice.

Metastases to abdominal lymph nodes
The clinical picture of abdominal metastases, as in the cases described above, will depend on which lymph nodes were affected. Thus, metastases in the intestinal mesentery are accompanied by intestinal colic, constipation, and in severe cases, intestinal obstruction. Metastases in the liver are accompanied by stagnation of venous blood in the 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 in first place for metastasis to the brain). Penetrating into the brain, metastases give a specific clinical picture.

Symptoms of brain metastases are:

• Nausea. May be a sign of both intoxication and intracranial pressure. In the second case, as the pressure increases, vomiting also occurs. Nausea in combination with headache is an unfavorable symptom.
• Bursting headaches. Initially, the headaches are moderate and go away with the use of analgesics. Then they become permanent and do not respond to painkillers. Headaches are often accompanied by dizziness and visual disturbances. This is often the first symptom indicating brain damage.
• Convulsive syndrome, which is manifested by large and small seizures of the epileptic type. Characteristic for patients over 45 years of age.
• Focal symptoms, which is individual and depends on the location of metastases. Thus, metastases in the right hemisphere are manifested by sensory disorders 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

Melanoma examination

The diagnostic criteria for malignant melanoma are as follows:

• the neoplasm protrudes unevenly above the surface of the skin;
• numerous erosions and bleeding ulcers;
• maceration ( softening);
• melanoma ulceration;
• development of accompanying nodules ( is a sign of metastasis);
• melanoma color variation - includes areas of red, white and blue on a brown or black background;
• increased color along the periphery of the melanoma, resulting in the formation of a ring of coal-black merging nodules;
• also, an inflammatory halo can form around the melanoma contour;
• in the area of ​​melanoma the skin pattern completely disappears;
• uneven edge with corners and jagged edges;
• blurred contour boundaries.

Questions that a dermatologist asks during a consultation may include the following:

• 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 inspection.
• Has the form changed? A previously round mole takes on irregular contours.
• Has the color changed? The appearance of various brown, red and blue shades on an old or new mole.
• Have there been any signs of inflammation before? Zones of hyperemia appear around the contour of the mole ( redness).
• Is oozing and bleeding typical?
• Is there itching and flaking?

What tests and studies are prescribed for melanoma?

Additional studies in the diagnosis of melanoma are:

• general examination– during general examination the doctor palpates the patient’s lymph nodes, determines their soreness, density, and adhesion to the tissues;
• chest x-ray ( sign up) – in order to determine whether 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 metastasis of melanoma, and it may also indicate resistance ( sustainability) tumors for treatment;
• ultrasonography ( Ultrasound) abdominal organs ( sign up) carried out to analyze the condition of internal organs and lymph nodes, recommended for patients with a melanoma thickness of more than one millimeter;
• dermatoscopy ( sign up) - a method that allows, using a special device ( similar in design to a microscope and connected to a computer) enlarge the suspicious formation hundreds of times and examine it in detail.

Melanoma ICD10

How to distinguish melanoma?

Characteristics of common skin lesions

Methods for studying melanoma are:

• indication of tumor with radioactive phosphorus;
• cytological examination;
• thermal differential test;
• biopsy ( sign up) .

Cytological examination
This method is simple and highly effective in determining the nature of melanoma and its metastases. Cytology involves examining tissue for cell morphology. In this case, the structure of the cells that make up the melanoma is examined. 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 the melanoma area and a symmetrical area of ​​healthy skin. It is carried out by measuring the temperature of each affected area using a thermometer. If average difference temperature is more than 1 degree, 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 research has shown that biopsy is a very valuable method in identifying early forms of melanoma.

The principles of biopsy are as follows:

• excision is performed in the shape of an ellipse, since with circular excision the thickness of the tumor may be incorrectly assessed;
• when performing a biopsy, the injection needle should not be inserted into the melanoma itself;
• The melanoma is excised at a distance of two millimeters from the edge.

Which doctor treats melanoma?

Treatment of melanoma

Treatment methods for melanoma are as follows:

• surgical treatment, which involves excision of the tumor;
• chemotherapy;
• radiation therapy;
• biological therapy ( immunotherapy).

Chemotherapy for melanoma

The most common treatment regimens are as follows:

• Roncoleukin 1.5 milligrams intravenously every other day in combination with bleomycin and vincristine. 6 cycles are carried out at intervals of 4 weeks.
• Roncoleukin 1.5 milligrams intravenously every other day in combination with cisplatin and reaferon. Similarly, 6 cycles at intervals of 4 weeks.

Surgical treatment of melanoma

The volume of tissue removed depends on the size and shape of the tumor. Thus, for superficial spreading and nodular melanoma, excision is performed at a distance of 1–2 centimeters from its edge. In this case, the excision is carried out along an ellipse, giving the block of excised tissue an ellipsoidal shape. Plastic surgery of the resulting defect takes place in two stages. First, with a synthetic absorbable material ( vicryl or polysorb) suturing the dermis. Then a second intradermal suture is made using non-absorbable sutures ( for example 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 extreme low temperatures. In the second case, tumor cells are destroyed under the influence of a laser.

Radiation therapy

Patient monitoring

The rules for clinical observation of patients with melanoma are as follows:

• during preventive examinations, 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

Our doctors, together with leading research institutes, are involved in the development of new drugs that make melanoma treatment more effective. Patients with melanoma should have access to information regarding experimental treatment programs. Unfortunately, patients and their loved ones do not receive truthful information about therapy and specific treatment strategies. The patient trusts the doctor, who cannot offer anything other than the drugs Dacarbazine and Interferon Alpha.

Let us remind you again

Melanoma can change the configuration of its proteins in a very short time. The growth rate is the highest of all types of tumors. And if it has metastasized throughout the body, traditional healing methods and the drugs are ineffective, doctors have nothing to offer other than supportive symptomatic therapy.

Basic diagnostic methods for metastases

Sentinel lymph node biopsy
- analysis for the BRAF-600 gene mutation,
- LDH analysis,
- check for mitotic activity.

Why chemotherapy doesn't help with melanoma

Melanoma is not sensitive to either chemotherapy or radiation therapy. The treatment of melanoma does not have an algorithm; it simply does not exist. For example, for lung cancer there are algorithms, there is an understanding of what drug regimens (protocols) to prescribe. In melanoma, the tumor can change the configuration of its proteins in a short time.

The proteins of melanoma cells are protected from the penetration of drugs, so the use of chemotherapy and interferons brings results in no more than 11% of cases and only for a short time - up to 6 months. Further, melanoma progresses significantly when immune function decreases.
Treatment of melanoma with chemotherapy suppresses the immune system, stopping the synthesis of antibodies, monoclonal bodies, and lymphocytes. Lymphocytes' main function is to protect the body from microbes and foreign tumor cells. But if the patient suppresses the activity of lymphocytes using chemicals and prevents them from multiplying, then there is no one to protect the body.

Melanoma surgery

Surgery is performed in the presence of a primary lesion. If necessary, lymph node dissection of the sentinel lymph node to prevent the spread of cancer cells along the lymph flow paths. Surgery as the only method of treating melanoma is used in the early stages of melanoma development without metastasis.

In this case, the tumor and surrounding skin are excised (at least 3-5 cm are removed from the edge of the tumor on the torso and limbs, 2-3 cm on the face), subcutaneous tissue, fascia or aponeurosis. Therefore, plastic surgery has to be performed frequently to close the wound defect.

Modern treatment of melanoma

Long-term observation has shown that the spread of metastases occurs in a period of 6 to 12 months, the average life expectancy of patients with metastases in one organ is 7 months, in two organs - 4 months, and in three or more - 2 months. Dacarbozine, other chemotherapy drugs and interferons increase life expectancy by only 9%, but they do not help everyone.

Which modern drugs It is possible to pay attention to patients.

We invite patients to take part in new methods of treating melanoma, as well as in clinical trials of new drugs

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