Melanoma: Symptoms and Treatment
Melanoma is a specific type of tumor malignant formation that forms on the skin, this formation is developed from melanin-synthesizing melanocytes of skin cells. Melanoma, the symptoms of which can appear in patients at any age (from adolescence), has recently become a fairly common disease that often leads to death, however, detection at an early stage does not exclude the possibility of cure.
Melanoma is only one of the varieties of existing skin pathologies of an oncological nature. The epidemiology of this disease in the countries of central Europe in the framework of the 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 somewhat higher and it is about 37-45 cases.
The data from one of the Berlin clinics indicate that on average about 14,000 cases of this disease are diagnosed annually in Germany, the ratio of the incidence rate indicating that here women are more exposed to it — 6 thousand cases are men , 8 thousand — for women. Mortality from melanoma in this case is determined by 2 thousand cases of the disease, this, in turn, determines about 1% of the overall consideration of the lethality for cancer.
The patients with the age of more than 70 years are most affected by melanoma. As we initially noted, recently melanoma has become quite a common disease, in particular, there is information that during the last fifty years the world incidence rates have increased by 600%.
Predominantly melanoma centers around the trunk and extremities of individuals whose skin type is Eastern European. Signs of melanoma are mostly found in blonde and red-haired patients with green, gray or blue eyes, and also with pink freckles. In addition to the genotype, atypical moles and nevi (congenital pigmentation spots) are identified as predisposing factors. In particular, nevuses become predisposing to the development of melanoma by the background when they are re-injured, as well as the location in the back, foot, foreleg and open areas of the body. Significantly more dangerous are those melanomas that develop against the background of acquired pigmentation, that is, when spots appear in patients of the mature age group. As the risk factors are also considered the effects of ultraviolet radiation, melanosis of Dubreia, heredity and pigment xeroderma, the presence of more than 50 moles, a significant number of freckles (including their rapid formation).
Despite the previously noted predisposition to the development of melanoma of Caucasian people, it should be borne in mind that this disease can develop in a person belonging to any race and with any skin color, that is, melanoma is not limited to the defeat of people with white skin color.
It should also be noted that the hairy nevuses never become malignant, respectively, if hair growth is detected when considering the pigmented tumor formation, then it should not be considered malignant.
Melanoma appears not only on the previously formed pigment spots, but also on healthy skin. Melanoma in women predominantly focuses on the lower extremities, while in men there is a tendency to develop melanoma mainly on the trunk (especially often on the back). Typical areas of tumor formation are those areas that are most susceptible to ultraviolet radiation. However, at the same time, such areas are not excluded on which ultraviolet radiation can hardly get into, in particular, interdigital spaces, esophagus, soles of the feet. The incidence of melanoma of infants and children is possible only as a rare exception, predisposing factor for the development of the pathological process becomes in this case the transfer of previously sunburn.
There are also certain differences in the degree of «malignancy» of the disease we are considering, here we mean the speed of melanoma development. Accordingly, a rapid disease is considered in the case of its development within a period of several months under the scheme «diagnosis — death», and long-term — with flow in conjunction with appropriate therapy within a period of 5 years or more.
As a very insidious manifestation of melanoma, early formation of metastases is determined, which occurs in certain organs in the body, which can lead to a fatal outcome for the patient. The heart, skin, lungs, liver, brain and bones of the skeleton are most often affected by metastases. Melanomas that do not spread further than the basal membrane in the skin cells (that is, the layer located between the epidermis layer and the dermis layer) determine the practical exclusion of the risk of metastasis.
As for the types of melanoma, as well as the frequency of their occurrence, their classification here is as follows:
- Surface-spreading melanoma — characterized by its slow growth, the incidence is greatest, is 47%
- Nodular melanoma — characterized by its own rapid growth, the frequency of occurrence is somewhat inferior to the previous form, determining a figure of 39%
- Peripheral Lentigo — the incidence rate is 6%, this form of the disease is defined as a precancerosis (or pre-cancer, ie a pathological condition in which tissue changes, like the very course of the processes, naturally precede cancer , And the long-term existence of the disease in this form most likely leads to its transition to cancer).
- Amelanotic melanoma (acrom melanoma) — is diagnosed extremely rarely, the focus area in this case is concentrated within the plantar and palmar surfaces.
Skin melanoma: symptoms
Before we proceed to a more detailed examination of the processes and symptoms accompanying the course of the disease, let us single out the main signs of melanoma, due to which it is possible to recognize it early, there are only five of them:
- the asymmetry of education (the irregularity of its shape)
- heterogeneity of the color of education: in some places the tumor is dark, in some it is light, and in some cases can be combined with practically black areas
- the edge of tumor formation is arcuate and uneven, fuzzy, may be barbs;
- diameter of tumor formation is 5 mm or more;
- the peculiarity of the location of tumor formation is that it is in a somewhat elevated position compared with the level of the surface of the skin (more than 1 mm).
About 70% of cases develop melanoma from the nevus (mole), mainly, that we have already noted, it focuses on the limbs, neck and head. In men, the chest and spine, as well as the upper limbs, are more likely to develop this type of tumor, and the lower extremities and breasts in women. The greatest danger is the epidermal (or borderline) nevus, which mainly occurs in men in the area of the skin of the scrotum, soles or palms. As the main signs that the malignancy of the process occurs, the increase in size, color change (weakening or intensification of color), the appearance of bleeding and infiltration of the skin (impregnation with a certain substance) in the environment of the nevus and under its base are distinguished.
Externally, melanoma resembles a tumor bundle of dense type, its color can be black or aspid, in some cases with a bluish tinge. The non-pigment melanoma is formed less often, and it can be understood that they are devoid of pigment, they have a pinkish hue. With respect to the dimensions, a diameter in the range of 0.5-3 cm can be isolated. In many cases, the tumor formation has a bleeding erosion surface and a somewhat densified base. Any of the listed signs allow you to make a primary independent diagnosis by means of a routine examination (but for him it is necessary to use a magnifying glass).
Within the course of the early stages of the disease, malignant formation is outwardly more harmless than in the subsequent stages, therefore it is possible to distinguish it from the pigment nevus of a benign type only by having sufficient experience for this.
Let us dwell on the three main common forms of melanoma, isolated earlier, or rather — on their features. In particular, we are interested in the surface-spread form of melanoma, nodal (nodular) melanoma, as well as malignant lentigo.
Malignant lentigo is characterized by the duration of the phase of its own horizontal growth, defined in the time interval ranging from 5 to 20 years, and in some cases even more. Typical cases of current are observed in the elderly in the area of open areas of the skin of the neck and face, which appear plaques or spots of brownish-black color.
Melanoma superficial-spread develops in patients of a younger age group (in this case their average age is 44 years). With regard to the development of tumor formation, there is the same frequency of its appearance in both exposed areas of the skin and in closed areas. In women, the lower limbs are mainly affected, and in men — the upper back. The forming plaque has an irregular configuration, the contour is scalloped, there are foci of discoloration and regression, the color is mosaic, keratosis appears on the surface (the thickening state of the epidermis layer). A few years later (about 4-5), a knot is formed on the plaque, which indicates the transition from horizontal growth to vertical.
Nodular melanoma acts as the most aggressive variant of tumor development. The age of patients exposed to this type of education averages 53 years, relative to the predisposition according to gender, the ratio 60:40 (male / female) is indicated. Most often, the localization process is concentrated in the area of the skin of the back, head and neck, as well as limbs. The node increases rapidly enough, the patients note such changes in it in the period of several months, accompanied by an increase in the formation of ulceration and its general 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 detection of a distant type of metastasis, which occurs in parallel with the detection of relapse, and sometimes until the time of its occurrence. Exclusively chemotherapeutic treatment is used in situations with common forms of the disease, with the relevance of distant metastases. In particular, combined treatment options using antitumor 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 a fairly pronounced metastasis, not only by the lymphogenous route, but also by hematogenesis. Predominantly, as we have already noted, the brain, liver, lungs, heart are affected. In addition, dissemination (spread) of tumor nodes along the skin of the trunk or limb often occurs.
It is not excluded that the patient’s treatment for the help of a specialist occurs solely on the basis of the actual enlargement of the lymph nodes of any area. Meanwhile, a thorough survey in this case can determine that a certain time ago, for example, he, as an achievement of the corresponding cosmetic effect, removed the wart. This «wart» actually turned out to be melanoma, which is subsequently confirmed by the results of a histological examination of the lymph nodes.
Melanoma of the eye: symptoms
Melanoma, in addition to skin lesions, is also a fairly common pathology of the eye, in which it manifests itself as a primary tumor formation. The main symptoms of the melanoma of the eye are the appearance of photopsy, progressive scotoma and impaired vision.
Photopsy in particular is a pathological condition in which flashing sparks, glowing dots, «flashes of light» and color spots appear in the field of vision. As for the manifestation such as scotoma, it is a blind area of a limited type that appears in the field of view, subjectively perceived by patients as a dark spot (in this case it is a positive scotoma) or is not perceived at all (scotoma is negative). Identification of the scotoma in the negative version is possible only with special research methods.
Often the small size of melanoma determines the complexity of differentiation with the pigmentary nevus, centered in the vascular eye area.
To determine the growth of tumor formation, repeated studies are necessary. As for the generally accepted tactics in treatment, there is no eye with melanoma. There is an eye enucleation and local resection, as well as radiation therapy.
Melanoma flow is determined by the specific stage, which corresponds to the patient’s state at a specific moment, there are only five of them: zero stage, I, II, III and IV stages. The zero stage allows to define tumor cells exclusively within the outer cell layer, their germination to the deep tissues at this stage does not occur.
I stage determines the size of the thickness of the tumor formation within a maximum of one millimeter, the epidermis (that is, the skin from the outside) is often ulcerated. Meanwhile, ulceration may also not appear, the thickness of the tumor formation can reach at the same time about two millimeters, the lymph nodes that are in close proximity to the pathological process, the cells do not suffer from melanoma.
stage II of tumor formation in melanoma determines for him dimensions of at least a millimeter in thickness or 1-2 millimeters of thickness when characteristic ulcers appear. To the same stage are also tumor formations, the thickness of which exceeds two millimeters, with 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 the immediate vicinity of it.
The next, III stage , is accompanied by a lesion of the pathological process of nearby tissues; in addition, the presence of tumor cells in one lymph node or in larger Their number, the affected lymph nodes are also in the immediate vicinity of the affected area of the skin. It is possible that melanoma cells can escape beyond the boundaries of the primary focus, but lymph nodes are not affected.
For stage IV , the progression of the disease 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 outside the melanoma.
As we have already noted, the recurrence of the disease is not excluded even with correctly defined and conducted treatment. The pathological process can return both to the area previously affected and to form in that part of the body that was not related to the previous course of the process.
Melanoma: prediction by stages
As the most important factor in this case, the clinical stage corresponding to the course of melanoma at the time of diagnosis is considered. Regarding survival in the I and II stages, in which tumor localization 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, at which metastasis occurs to regional lymph nodes, the survival rate for the specified 5-year period is reduced to 50% with the involvement of one lymph node and about 20% — in case of lesion of several lymph nodes. As part of the consideration of stage IV, accompanied by distant metastasis, survival for the next five years is no more than 5%.
A positive point in the overall picture of the disease, directly related to the prognosis for it, is that in most cases melanoma is detected during the I and II stages. The prognosis in this case is determined on the basis of the thickness of the tumor formation, because exactly the thickness indicates the mass that is relevant for the tumor, the mass of the tumor determines the probability of subsequent possible metastasis.
With a thickness of tumor formation within 0.75 mm, the prognosis of successful cure due to surgical intervention is determined, as for survival within the standard period of 5 years, then it is relevant in 96-99% of cases. Approximately to date, it can be pointed out that in about 40% of cases of sickness in patients, tumor formation is detected within its thickness up to 1 mm, while the patients themselves are then identified in the so-called low risk group. In those patients with metastases, the histological examination of primary tumor formation determines either its vertical growth or spontaneous regression.
With a thickness of melanoma over 3.64 mm, metastasis occurs in almost 60% of cases, a similar course entails a fatal outcome for the patient. In most cases, tumors that are similar in size, are significantly distinguished against the general background of the skin, noticeably towering above it.
In general, the forecast directly depends on where the tumor is located. Thus, the most favorable character of the prognosis is determined by the localization of tumor formation in the region of the shins and forearms, the unfavorable prognosis, in turn, is determined when it is localized in the region of the feet, brushes, scalp, and mucous membranes.
There is a certain trend in this regard regarding gender. So, I and II stages are characterized by a better prognosis for women than for men. To some extent, this trend is due to the fact that mainly the tumor in women is localized in the region of the shins, where it is easier to detect by self-examination, which in turn makes possible further treatment during the early stages, when the prognosis is of such a favorable nature .
When considering the prognosis of melanoma for elderly patients, it can be noted that here it is less favorable, due to the late detection of the tumor, as well as the high susceptibility of elderly men to the acar lentiginous melanoma.
The prognosis of recurrence of the disease is based on general statistics, according to which about 15% of cases of relapses appear more than five years after the removal of tumor formation. The main regularity here is this: the thicker the size of the tumor, the faster it is subject to subsequent recurrence.
As factors for the prognosis during the I and II stages, such factors as ulceration of tumor formation, increased mitotic activity, and the formation of satellites (peculiar islands of tumor cells, in diameter reaching sizes from 0.05 mm and more ). The latter focus outside the main focus of the tumor, within the mesh layer of the dermis or in the subcutaneous tissue. Also satellites in most cases melanoma arise together with micrometastases directed to regional lymph nodes.
Stage I and II melanoma can also be predicted in its course and by using another method — the method of comparing Clark’s histological criteria. I level of invasion according to the Clarke criteria system determines the location of tumor formation within the epidermis layer, the second level of invasion indicates tumor germination in the dermis (papillary layer), level III determines the reaching of the border by the tumor between the mesh and papillary dermis layer, IV indicates its germination In the mesh layer, V determines its penetration directly into the subcutaneous tissue. According to each of these levels, the survival rate is 100 and 95%, 82 and 71%, and 49% (for the latter option).
In the diagnosis of melanoma, in addition to a standard examination using a magnifying glass for this purpose, a radioisotope study is also used in which the detection of an increased amount of phosphorus in the tumor formation indicates that it is malignant. Skin cancer is usually diagnosed with biopsy or puncture, but with melanoma, such intervention should be excluded, because even the slightest impact can determine trauma, which in turn can lead to a rapid generalization of the pathological course of the process.
Given these conditions, the only method for clarifying the diagnosis is a cytological study, which examines the imprint from the surface of the tumor in the case of the actual ulceration. The remaining cases of the course of the pathological process imply the diagnosis of the disease only on the basis of clinical manifestations.
In the collection of the anamnesis, a special interest is directed toward the symptomatology characteristic of metastases (general malaise, joint pain, visual impairment, headache, weight loss). In addition, to exclude or confirm the presence of metastases to internal organs allows the use of such methods as ultrasound, CT and radiography. Having completed the general examination for the relevance of melanoma, they proceed to determine its stage and the appropriate treatment.
Treatment of melanoma
In treatment of melanoma, two methods are used, this is only a surgical method and a combined method. The combined method is considered to be most reasonable, because after the irradiation the removal of the tumor formation is ablastic. In the first stage of this treatment, the method of close-focus X-ray exposure to the tumor is applied, after which, before the onset of the radiation reaction (2-3 days after the completion of the exposure) or after its disappearance, its broadband excision is performed while capturing several centimeters of healthy skin. The wound defect arising in this case is subject to cutaneous plasty.
Given that malignant melanoma is characterized by a rapid transition to metastasis to the lymph nodes in the vicinity, it is necessary to remove the regional lymph nodes, even in the absence of their increase as such. If the lymph nodes are enlarged and there is a suspicion of metastasis, then they are pre-irradiated by applying measures of a remote type of gamma therapy. In recent years, a complex approach to treatment, based on the addition of radiotherapy and surgical methods to chemotherapy procedures, has often been used.
It should be borne in mind that in the presence of nevi and in particular with any changes associated with them, whether color change, the appearance of ulceration, an increase in size or bleeding, it is important to immediately take measures, which in this case reduce to surgery. Also note that the III and IV stages of melanoma are incurable today, therefore, taking this into account, the main measures in combating it are prevention and early diagnosis. In case of symptoms that indicate melanoma, it is necessary to consult an oncologist and a dermatologist.