Melanoma is a specific type of malignant tumor that forms on the skin; this formation develops from melanin melanocytes of skin cells. Melanoma, the symptoms of which can manifest in patients at any age (with adolescence), has recently become a fairly common disease, often fatal, however, its detection in the early stages does not exclude the possibility of a cure.
Melanoma is only one of the varieties of oncological skin pathologies that exist. The epidemiology of this disease in the countries of Central Europe in the framework of the review of annual indicators corresponds to the ratio of 10 cases of its occurrence per 100,000 inhabitants. For the same number of people in the southern states of America and in Austria, the incidence is slightly higher and is about 37-45 cases.
The data of one of the Berlin clinics indicate that on average around 14,000 cases of this disease are diagnosed annually in Germany, and the ratio of the incidence of incidence indicates that here women are more susceptible to it - 6,000 cases occur in men, 8,000 - on women. Mortality from melanoma in this case is determined by 2 thousand cases of the disease, which, in turn, determines about 1% of the overall consideration of mortality for cancer.
Most patients with melanoma are patients over 70 years old. As we initially noted, melanoma has recently become a fairly common disease, in particular, there is information that over the past fifty years, global incidence rates have increased by 600%.
Predominantly melanoma is concentrated in the region of the trunk and extremities in persons whose skin type belongs to Eastern European. Symptoms of melanoma are mostly observed in blond and red-haired patients with green, gray or blue eyes, and pink freckles. In addition to the genotype, the presence of atypical moles and nevi (congenital pigment spots) are distinguished as predisposing factors. In particular, nevi become a predisposing background for the development of melanoma when they are re-injured, as well as being located in the back, foot, shoulder girdle and open areas of the body. Significantly more dangerous are those melanomas that develop on the background of acquired pigmentation, that is, when spots appear in patients of the group of mature age. Exposure to ultraviolet radiation, Dubrei's melanosis, heredity and xeroderma pigmentosa, the presence of more than 50 moles, a significant number of freckles (including their rapid formation) are also considered as risk factors.
Despite the previously noted predisposition to the development of melanoma of white-skinned people, it should be borne in mind that this disease can develop in a person belonging to any race and any skin color, that is, melanoma is not limited to damage to people with white skin.
It should also be noted that hairy nevi never become malignant, respectively, if, when considering the pigment tumor formation, hair growth is detected, then it should not be considered malignant.
Melanoma appears not only on previously formed age spots, but also on healthy skin. Melanoma in women focuses primarily on the lower limbs, while men tend to develop melanoma mainly on the body (especially often on the back). Typical areas of tumor formation are those areas that are most susceptible to exposure to ultraviolet radiation. However, at the same time, such areas are not excluded, on which ultraviolet radiation is almost impossible to get, in particular, it is interdigital spaces, esophagus, soles of the feet. The incidence of melanoma in infants and children is possible only as the rarest exception, in which case they suffer from sunburn as a predisposing factor for the development of the pathological process.
There are also certain differences in the degree of "malignancy" of the disease under consideration, here we mean the speed of development of melanoma. Accordingly, a fast disease is considered if it develops within a period of several months according to the “diagnosis of a lethal outcome” scheme, and long-term with a course in combination with appropriate therapy within a period of 5 years or more.
As a very insidious manifestation of melanoma is determined by the early formation of metastases, which occurs in various organs in the body, due to which a death may subsequently occur for the patient. Most often, heart, skin, lungs, liver, brain and skeleton bones are affected by metastasis. Melanomas that have not spread further than the basement membrane in the skin cells (that is, the layer located between the epidermis and the dermis) determine the practical exclusion of the risk of metastasis.
As for the types of melanoma, as well as the frequency of their occurrence, here their classification is as follows:
Before we move on to a more detailed examination of the processes and symptoms associated with the course of the disease, let us single out those basic signs of melanoma, due to which it is possible to recognize it early, there are five:
About 70% of cases develop melanoma from a nevus (mole), mainly that we have already noted, it concentrates in the limbs, neck and head. In men, the thorax and back, as well as the upper limbs, are more susceptible to the appearance of this type of tumor, in women - the lower limbs and the chest. The greatest danger is the epidermal (or borderline) nevus, which predominantly occurs in men in the skin of the scrotum, soles or palms. As the main signs that the process is malignant, an increase in size, color change (weakening or intensification of color), the appearance of bleeding and skin infiltration (soaking with a certain substance) surrounded by a nevus and under its base are distinguished.
Outwardly, melanoma resembles a tumor nodule of a dense type, its color may be black or aspidnym, in some cases with a bluish tinge. The less pigmented melanomas are formed less often, according to the definition it can be understood that they are devoid of pigment, they have a pinkish tint. Regarding the size, a diameter in the range of 0.5–3 cm can be distinguished. In frequent cases, the tumor mass has a bleeding eroded surface and a slightly compacted base. Any of these symptoms allow you to make a primary independent diagnosis through a routine examination (but it is necessary to use a magnifying glass for it).
As part of the course of the early stages of the disease, a malignant tumor is seemingly more harmless than at further stages; therefore, it can only be distinguished from a pigmented nevus of a benign type by having sufficient experience.
Let us dwell on the three main common forms of melanoma that we have previously identified, or rather, on their features. In particular, we are interested in the surface-prevalent form of melanoma, nodular (nodular) melanoma, and also malignant lentigo.
Malignant lentigo characterized by the duration of the phase of its own horizontal growth, determined in the time interval from 5 to 20 years, and in some cases more. Typical cases of flow are observed in the elderly in the open areas of the skin of the neck and face, on which plaques or patches of brown-black color appear.
Melanoma superficial develops in patients of a younger age group (in this case, their age averages 44 years). As for the area of development of tumor formation, there is the same frequency of its occurrence in open skin areas and in closed areas. In women, lower limbs are mainly affected, and in men, the upper back is affected. The forming plaque has an irregular configuration, the contour is scalloped, there are pockets of discoloration and regression, the color is mosaic, keratosis appears on the surface (the state of thickening of the epidermis layer). After a few years (about 4-5), a knot forms on the plaque, which indicates the transition of the process from horizontal to vertical.
Nodular melanoma It acts as the most aggressive type of development of the tumor. The average age of patients with this type of education is 53 years; a ratio of 60:40 (men / women) is indicated relative to predisposition according to gender. Most often, the localization process focuses on the skin of the back, head and neck, as well as limbs. The node grows quite quickly, patients notice such changes in it in a period of several months, accompanied by an increase in the formation of ulcerations and its overall bleeding.
As a direct consequence of the use of non-radical measures in the treatment of melanoma are its relapses. Such cases are often accompanied by the identification of a distant type of metastasis, which occurs in parallel with the detection of relapse, and sometimes even before its occurrence. Exclusively chemotherapy treatment is used in situations with common forms of the disease, with the relevance of distant metastasis. In particular, combined treatment options with the use of anticancer drugs are used, which determines the possibility of regression of tumors in the order of up to 40% of cases.
Malignant melanoma is prone to fairly pronounced metastasis, and not only by lymphogenous, but also by hematogenous. As we have already noted, the brain, liver, lungs, and heart are mainly affected. In addition, dissemination (spreading) of tumor nodules along the skin of the trunk or limb often occurs.
Not excluded the option in which the patient's request for the help of a specialist occurs solely on the basis of the actual increase in the lymph nodes of any area. Meanwhile, a careful survey in this case can determine that a certain time ago, for example, he, as an achievement of the corresponding cosmetic effect, removed a wart. Such a “wart” actually turned out to be melanoma, which was later confirmed by the results of a histological examination of the lymph nodes.
Melanoma, in addition to skin lesions, is also a fairly common eye pathology, in which it manifests itself as a primary tumor formation. The main symptoms of melanoma of the eye are photopsy, progressive scotoma and vision impairment.
Photopsies in particular are such a pathological condition in which flickering sparks, glowing points, “flashes of light” and color spots appear in the field of view. As for such a manifestation as scotoma, it is a blind area of a limited type appearing in sight, subjectively perceived by patients as a dark spot (in this case it is a positive scotoma), or not perceived at all (scotoma negative). Identification of scotomas in the negative version is possible only when conducting special research techniques.
Often the small size of melanoma determines the difficulty in differentiation with pigment nevus, concentrated in the area of the vascular eye membrane.
To determine the growth of tumor formation is necessary to conduct repeated studies. As for the generally accepted tactics in treatment, it does not exist for melanoma of the eye. Ocular enucleation and local resection as well as radiation therapy are performed.
The course of melanoma is determined by a specific stage, which corresponds to a specific moment of the patient's condition, there are five of them: stage zero, stage I, II, III and IV. The zero stage allows to determine tumor cells exclusively within the outer cell layer, their germination to deep-lying tissues at this stage does not occur.
Stage I determines the size of the tumor mass within the limits not exceeding one millimeter; the epidermis (that is, the skin on the outside) is often covered with ulcerations. Meanwhile, ulcerations may also not appear, the thickness of the tumor formation may reach about two millimeters, lymph nodes located in close proximity to the pathological process, are not affected by melanoma cells.
Stage II tumor formation in melanoma determines for him the size of not less than a millimeter in thickness or 1-2 millimeters of thickness with the appearance of characteristic ulcerations. The same stage includes tumor formations, the thickness of which exceeds two millimeters, with the possible ulceration of their surface or with a surface without ulcers. At this stage, melanoma in any of these options does not apply to the lymph nodes located in close proximity to it.
Next, Stage III, accompanied by damage to the pathological process of nearby tissues, in addition to the study revealed the presence of tumor cells in one lymph node or in a larger number of them, the affected lymph nodes are also in close proximity to the affected area of the skin. The possibility of melanoma cells escaping beyond the boundaries of the primary focus is not excluded, but the lymph nodes are not affected.
For Stage IV disease progression is characterized by the spread of tumor cells to the lymph nodes, as well as to neighboring organs and those areas of the skin that are located further, beyond the limits of melanoma.
As we have already noted, the recurrence of the disease is not excluded, even with correctly defined and carried out treatment. The pathological process can return to the area that was previously affected, and can form in that part of the body that was not related to the former course of the process.
In this case, the clinical stage corresponding to the course of melanoma at the time of diagnosis is considered as the most important factor. Regarding the survival in stages I and II, in which the tumor is concentrated within the boundaries of the primary focus, the survival rate for the next five years is approximately 85%. In the case of stage III of the course of the disease, in which metastasis to regional lymph nodes occurs, the survival rate for the specified 5-year period is reduced to 50% if the process affects one lymph node and about 20% - if several lymph nodes are affected. As part of the review stage IV, accompanied by distant metastasis, the survival rate for the next five years is not more than 5%.
A positive point in the overall picture of the disease, directly related to the predictions for it, is that in most cases melanoma is detected in the period I and II stages. The prognosis in this case is determined on the basis of the thickness of the tumor, because it is the thickness that indicates the mass that is relevant for the tumor, the mass of the tumor determines the likelihood of subsequent possible metastasis.
When the tumor mass thickness is within 0.75 mm, the prognosis for a successful cure due to surgical intervention is determined, as regards survival within the standardly considered period of 5 years, here it is relevant in 96-99% of cases. Approximately today, it can be pointed out that in about 40% of cases of morbidity in patients a tumor is detected within its thickness of up to 1 mm, while the patients themselves are then in the so-called low-risk group. In those patients who develop metastases, a histological examination of the primary tumor formation determines either its vertical growth or spontaneous regression.
With a melanoma thickness of more than 3.64 mm, metastasis occurs in almost 60% of cases, such a course entails a lethal outcome for the patient. In most cases, tumors having a similar size, significantly stand out against the general background of the skin, noticeably rising above it.
In general, the prognosis directly depends on where the tumor is located. Thus, the most favorable nature of the prognosis is determined when the tumor is localized in the region of the legs and forearms, the unfavorable prognosis, in turn, is determined when it is localized in the area of the feet, hands, scalp, and mucous membranes.
There is a certain trend in this regard in terms of gender. So, I and II stages are characterized by a better prognosis for women than for men. To some extent, this tendency is due to the fact that predominantly the tumor in women is localized in the region of the legs, where it is easier to detect during self-examination, which, in turn, makes possible subsequent treatment during the early stages, in which the prognosis is so favorable. .
When considering the prognosis for melanoma for elderly patients, it can be noted that it is less favorable here, due to the late detection of the tumor, as well as the high susceptibility of elderly men to acral lentiginous melanoma.
The prognosis for disease recurrence is based on general statistics, according to which about 15% of relapses occur more than five years after the removal of the tumor. The main pattern here is the following: the thicker the tumor is, the faster it is subject to subsequent recurrence.
As unfavorable factors for prognosis in the period I and II stages, such factors as ulceration of tumor formation, increased mitotic activity, as well as the formation of satellites (peculiar islands of tumor cells, reaching 0.05 mm or more in diameter) are distinguished. The latter are concentrated outside the main tumor site, within the framework of the reticular layer of the dermis or in the subcutaneous tissue. Also, satellites in most cases of melanoma occur along with micrometastases directed to regional lymph nodes.
Melanoma stage I and II can also be predicted in its course and through the use of another method - the method of comparison of Clarke's histological criteria. I level of invasion in accordance with the system of criteria Clarke determines the location of the tumor formation within the epidermis layer, II level of invasion indicates germination of the tumor in the dermis (papillary layer), level III determines the achievement of the border between the tumor and the reticular and papillary layer of the dermis in the mesh layer, V determines its penetration directly into the subcutaneous tissue. Accordingly, each of these levels of survival is 100 and 95%, 82 and 71%, as well as 49% (for the latter option).
In the diagnosis of melanoma, in addition to the standard examination through the use of a magnifying glass for this purpose, a radioisotope study is also used, in which the detection of an increased amount in the formation of phosphorus in the tumor indicates that it is malignant. When skin cancer is usually used in the diagnosis of this disease, a biopsy or puncture method is used, however, for melanoma, such intervention should be excluded, because even the slightest impact can determine trauma, and this, in turn, can lead to a violent generalization of the pathological process.
Given these conditions, the only method to clarify the diagnosis is a cytological study, which examines the imprint from the surface of the tumor in the case of actual ulceration. The remaining cases of the pathological process imply diagnosing the disease only on the basis of clinical manifestations.
The collection of anamnesis of particular interest is directed to the symptoms characteristic of metastases (general malaise, pain in the joints, blurred vision, headache, weight loss). Additionally, to exclude or confirm the presence of metastases to the internal organs allows the use of such methods as ultrasound, CT and X-ray. Having completed a general examination for the relevance of melanoma, they proceed to the determination of its stage and the corresponding prescription of treatment.
In the treatment of melanomas, two variants of methods are used, this is only a surgical method and a combined method. The combined method is considered to be the most reasonable, because after the irradiation is performed, the tumor is removed ablastically. Within the framework of the first stage of such treatment, a method of close-focus X-ray exposure to a tumor is applied, after which, until the onset of the radiation reaction (2-3 days after the end of the exposure) or after its subsidence, its broadband excision is performed when seizing several centimeters of healthy skin. The wound defect arising at the same time, is subject to skin plastics.
Given that malignant melanoma is characterized by its rapid transition to metastasis to nearby lymph nodes, it is necessary to remove regional lymph nodes even in the absence of their increase as such. If the lymph nodes are enlarged and metastasis is suspected, then they are pre-irradiated using measures of a remote type of gamma therapy. In recent years, an integrated approach to treatment based on the supplementation of the radiotherapy and surgical method with chemotherapy procedures has often been applied.
It should be borne in mind that in the presence of nevi and in particular with any changes associated with them, whether it is a change in color, appearance of ulcerations, an increase in size or bleeding, it is important to immediately take measures, which in this case amount to surgical intervention. We also note that the III and IV stages of melanoma today are incurable, therefore, considering this, the main measures in the fight against it are prevention and early diagnosis. In case of symptoms that indicate melanoma, you should contact an oncologist and a dermatologist.