Melanoma is a malignant neoplasm that is still difficult to treat effectively. The most important role in the fight against melanoma is played by the prevention and early diagnosis of the disease, which significantly increase the chances of a cure. Melanoma is not always a skin cancer, although it is most often associated with it. What are the symptoms of melanoma? What does skin melanoma, nail melanoma, nodular melanoma look like? How is melanoma diagnosed and how is it treated? How long does the melanoma metastasize? How Much Can You Live With Malignant Melanoma?

Czerniak - characteristics

Melanoma(malignant melanoma, Latinmelanoma malignum ) is a cancer of the skin, mucous membranes or uvea that originates from melanocytes. Contrary to popular belief, most melanomas, even in patients with multiple moles, arise de novo, i.e. not on the basis of a pre-existing pigmented nevus, but on he althy skin.

Experts warn that the incidence of melanoma is systematically increasing worldwide - the incidence of this cancer is increasing every year by 3-7 percent (in Poland, 2.6 percent for men and 4.4 percent for women). Of course, this is partly due to greater detectability and public awareness, but it is most likely also related to increased exposure to natural and artificial ultraviolet radiation.

Melanoma is a cancer with a high degree of malignancy - it can metastasize to nearby lymph nodes and distant metastases (e.g. to other areas of the skin, lungs, liver).

The area in whichmelanomaoccurs is related to age. In young people it usually appears on the chest (men) or the lower legs (women). In older people, it is most common on the face. Melanoma in the trunk reaches its peak in the fifth and sixth decade of life, and in the head and neck in the eighth decade.

Melanoma is a cancer that is still difficult to treat effectively. Therefore, the most important role in the fight against it is played by prevention and early diagnosis of skin disease. If the disease is diagnosed early, the chances of a cure are very good. Unfortunately, it is not uncommon for the disease to come back, often indicating that the cure was fake.

Patients' prognosis worsens in advanced forms of melanoma - 5-year survival rates in patientsDepending on the source, Europe is between 41% and 71% in the regional stage of advancement and between 9% and 28% in the generalized stage.

Melanoma: risk factors

Most melanomas, even in patients with multiple moles, arise de novo, i.e. not on the basis of a pre-existing pigmented nevus, but on he althy skin.

Only 25-40 percent of melanomas develop in association with a melanocytic nevus. However, it is estimated that people with more than 50 melanocytic nevi have a 5-fold increase in melanoma risk compared to people with less than 10 moles.

Sunscreens do not protect against melanoma, but - paradoxically - they increase the risk of its appearance due to the fact that they increase the exposure time to radiation.

The risk factors for melanoma are:

  • excessive exposure to UVA and UVB radiation, both solar and artificial (solariums)
  • high cumulative exposure to the sun, sunburn in childhood and adolescence
  • age and gender - women are more at risk, with risk increasing with age
  • light skin phenotype - light skin, light hair and eyes color, presence of freckles, easy sunburn
  • occurrence of melanoma in first and second degree relatives
  • previous occurrence of melanoma in the same patient - about 5-10 percent of people with previous melanoma will develop it again
  • presence of other non-melanoma skin cancer, including basal cell carcinoma, squamous cell carcinoma
  • dysplastic nevus syndrome
  • large number of pigmented (melanocytic) nevi and large congenital pigmented nevus
  • parchment skin ( xeroderma pigmentosum ) - 100 times increased risk
  • high socioeconomic status
  • immunosuppression and organ transplantation
  • iatrogenic exposure to ultraviolet radiation with psoralen - photochemotherapy (PUVA)
  • probably ionizing radiation

Melanoma: symptoms

Any change in the already existing birthmarks should be a cause of concern - dark, blue, bluish, black, and colorless ones.

Consultation with a doctor (oncologist, oncologist surgeon, dermatologist) should be prompted by the appearance of, among others:

  • thickening
  • redness around the birthmark
  • itching
  • bleeding
  • magnification
  • color changes
  • changing the shape of the birthmark.

Likedoes melanoma look like?

Such changes within the birthmark, which evoke oncological anxiety, are described by specialists with the abbreviationABCD , where:

  • A (from Englishassymetry ) is asymmetry, changing the shape of the birthmark from round to asymmetrical
  • B (from Englishborder ) are uneven or jagged edges
  • C (from Englishcolor ) is a color, i.e. a color change, e.g. darkening, lightening or different colors on one birthmark
  • D (fordiameter ) is the size - any mark larger than 6 mm in diameter should be carefully examined

Sometimes an additional symptom is included in the ABCD system: E ( elevation ) - elevation of the surface above the level of the surrounding epidermal lesion.

If you notice any disturbing changes, contact a dermatologist - unfortunately a referral is necessary. If the birthmark begins to itch, peel, bleed or seep from it, you can immediately visit the nearest oncology clinic - then you do not need a referral.

Czerniakowi can be accompanied, although very rarely, by paraneoplastic syndromes:

  • dermal - dermatomyositis, vitiligo, systemic sclerosis, paraneoplastic pemphigus, melanosis,acanthosis nigricans
  • ocular - melanoma associated retinopathy
  • hematological - leukemic reaction, eosinophilia, neutropenia
  • metabolic - hypercalcemia, Cushing's syndrome, hypertrophic osteoarthritis
  • neurological - chronic demyelinating polyneuropathy

Czerniak - photos:

See gallery 4 photos

How to recognize melanoma? See the video

Czerniak: types

There are 40 types of this neoplasm hidden under the name "melanoma". In 60% of them, the genotype of the neoplasm is known, which allows doctors to choose the most effective form of therapy. Specialists distinguish the following types of melanoma (WHO classification):

  • superficial spreading melanoma(SSM,superficial spreading melanoma ) - the most common, estimated to be about 60 percent of cases
  • lentigo melanoma(light brown skin lesion) called lentiginal melanoma (LMN,lentigo malignant melanoma ) - it is estimated, that it accounts for up to 20 percent of cases, relatively mild, developing over many years, mainly in the elderly; the starting point are flat spots of the color of coffee with milk, with irregular outlines and uneven distribution of the dye, a dozen in diameterup to several dozen millimeters, mainly on the face and in exposed places, the first symptom of malignant nodules is the formation of palpable nodules
  • nodular melanoma(NM,nodular melanoma ) - estimated to be around 5 percent of cases, is a hyperpigmented, rapidly growing the lump that ulcerates, develops mainly on the head, back and neck, is more common in men, metastasizes quite quickly, the 5-year survival period (despite treatment) is about 30 percent
  • subungual, subungual-limb melanoma(ALM,acral lentiginous melanoma )
  • blue nevus melanoma melanoma arising from blue naevus
  • congenital melanoma melanoma arising in a giant congenital naevus
  • melanoma(Eng.naevoid melanoma )

Czerniak: diagnostics

The most important thing is skin self-control - when any of the ABCD (E) changes occur, you need to see a doctor. Initial assessment is performed with a dermatoscope - an optical device that visualizes deeper changes in the birthmark. If melanoma is suspected, the doctor removes the entire nevus with a margin of he althy skin, and the removed fragment is submitted for histopathological examination, which determines the type of the diseased tissue and the stage of the disease.

Another examination is ultrasound, the so-called regional lymphatic area, which shows if there are no metastases in the nodes. When the test does not give a clear answer, the sentinel node is removed - the first lymph node on the path of the lymphatic vessels running from the tumor to the lymphatic system.

Additional tests to assess the advancement of melanoma are:

  • basic blood tests (complete blood count, liver tests, lactate dehydrogenase (LDH) activity)
  • Chest X-ray in posterior anterior and lateral projection
  • ultrasound of the abdominal cavity
  • possibly ultrasound of regional lymph nodes

Extended diagnostics - CT or PET tests - is performed in patients diagnosed with stage III skin melanomas (especially in the presence of clinical metastases to the lymph nodes) or isolated metastases to distant organs, while in the case of inguinal lymph node metastases it is recommended there is a pelvic KT examination.

In patients with metastases of melanoma to the lymph nodes or skin from an unknown primary tumor, any existing (or removed in the past without histopathological examination) primary lesion (especially on the skin) is searched forhairy head, mucous membranes).

Czerniak: stages

The stage of melanoma is given in the TNM classification:

  • T - primary focus, i.e. skin lesion
  • N - talks about the presence of lymph node metastases
  • M - defines the occurrence of metastases to distant organs

The different levels of the TNM scale, according to which doctors choose the best treatment and determine the prognosis, mean:

  • grade 0 - carcinoma in situ, i.e. a form that does not exceed the epidermis and does not infiltrate
  • Grade I - at this stage there are no lymph nodes involved, no metastases, and the tumor, if it is ulcerated, does not exceed 1 mm in thickness, and if there is no ulceration, then it does not exceed 2 mm
  • stage II - melanoma occurs only locally; this grade is divided into 3 grades, depending on the thickness of the primary lesion: A - lesion with ulceration up to 2 mm thick, and non-ulcerated lesion up to 4 mm B - lesion with ulceration up to 4 mm thick, without ulceration may be greater C - lesion thickness from ulceration greater than 4 mm
  • stage III - metastases to regional lymph nodes; it is important to determine their number and type of infiltration
  • stage IV - the most advanced stage of the disease, in which metastases occur in distant organs such as the lungs or the liver.

In addition, in the diagnosis of melanoma, scales to assess the depth of melanoma infiltration play an important role. They are:

  • Breslow Scale

Stage I - infiltration depth=4 mm

  • Clark's Scale

Stage I - infiltration is limited to the epidermis Stage II - infiltration covering the upper papillary layer of the skin Stage III - infiltrating the entire papillary layer Stage IV - infiltrating the reticulate layer of the skin Stage V - infiltrating the subcutaneous tissue

The clinical stages of melanoma are presented in the table below:

GradeCharacteristics
0form not exceeding the epidermis and non-infiltrating, carcinoma in situ
Ino lymph node involvement, no metastases, tumor with or without ulceration no greater than 1 mm<2 mm
IIno involvement of lymph nodes, no metastases, there are 3 grades (IIA, IIB, IIC), in which the decisive feature is the thickness of the primary lesion
IIImetastases to regional lymph nodes
IVmetastases in distant organs, e.g. lungs and liver

At diagnosis, in approximately 80% of patients, skin melanoma is a local lesion and is characterized by a very low risk of recurrence (3-15%). The regional advancement stage occurs primarily in approx. 15%, while the generalization stage - in approx. 5% of patients.

Czerniak: treatment

The total annual indirect costs of melanoma (negative impact of the disease on professional activity) amount to approx. PLN 250 million (taking into account discounting, i.e. lower present value of future costs, normally expressed as a standard rate of 5% annually) or approx. PLN 380 million (without discounting ). The vast majority of indirect costs result from premature mortality in the pre-retirement period.

Czerniak is on the 20th place in terms of the number of cancer deaths in Poland, compared to the European average on the 17th place!

The first stage of melanoma treatment issurgical treatment . It consists in a radical excision of the neoplasm with a margin of he althy skin 1 cm wide for melanoma up to 2 mm thick.

When the thickness of the infiltration is greater than 2 mm, 2-3 cm of he althy skin is removed, with a margin greater than two centimeters reducing the rate of local recurrences but not improving the survival rates. The surgeon must also remove the superficial fascia to make sure that no cancer cells are left in it.

If lymph nodes are enlarged, they will also be removed. In the case of small tumors, the fascia is not removed, only the sentinel node is assessed, i.e. the first node in the path of the lymphatic vessels leading from the tumor side towards the regional lymphatic system. The next stage of the operation is to close the wound. If the surgeon has had to remove a lot of skin, a skin graft is required, which is usually taken from the thigh.

In advanced form - when melanoma has crossed the skin-epidermal barrier and entered the lymph nodes or other organs (disseminated melanoma) - apart from surgery, supportive treatment is required. Depending on the patient's condition, the following applies:

  • chemotherapy
  • immunotherapy
  • radiotherapy

Recent years have brought a breakthrough in the treatment of melanomas. The reason for this was the discovery of the relationship between the BRAF gene mutation and the progression of melanoma. This knowledge has led to the development of molecularly targeted therapy, which consists in blocking the abnormal protein encoded by the mutated BRAF gene. This gene is present in more than half of all melanoma patients. Action of a new drug(vemurafenib) works by closing the door to cancer cells - they cannot feed and die programmed. Thanks to this, the tumor does not grow larger. The therapy is effective in 90 percent. sick.

  • prefusion chemotherapy

Isolated limb perfusion chemotherapy is used when skin or subcutaneous tissue has metastasized but more than 2 cm from the edge of the primary tumor. The therapy is based on the administration of high doses of anti-cancer drugs to the limb isolated from the systemic circulation. Then the limb is heated to 41-42 ° C, which allows it to destroy cancer cells.

  • radiotherapy

Radiotherapy is used to treat melanomas when the patient cannot (or does not agree to) surgery and as local treatment when radical surgery is not possible.

Radiotherapy is also used as an adjuvant treatment after surgery when it is suspected that, for technical reasons, the entire tumor has not been removed. It is also a palliative treatment method when bone metastases have occurred.

In the case of melanoma of the eyeball, radiotherapy is an adjunct treatment. In melanomas, chemotherapy is not used routinely as an adjuvant treatment after surgery. The reason is the low effectiveness of traditionally used chemotherapy. If a doctor decides to administer it, they usually do it to - in the advanced stages of the disease - alleviate the symptoms of the cancer.

  • targeted therapy

Targeted therapy raises great hopes among patients with metastases and among doctors themselves. Modern drugs work in many ways. They can neutralize the mutant BRAF protein and thus stop the growth of cancer cells. They can also stop disease resulting from mutations in the C-kit gene by inhibiting its proteins, which signal to cell growth.

In modern oncology, it is also possible to combine new drugs with those successfully used in other types of cancer, and to obtain a two-stage blast effect. Such a cocktail stimulates its own immune cells, which actively fight cancer and at the same time destroy existing cancer cells.

Note! Immunotherapy, especially with the use of biomodulators such as interferon, even in combination with chemotherapy, does not bring the expected results. It is similar with vaccines, which have not proved to be an effective weapon in the fight against melanoma.

Diffuse (generalized) skin melanoma: treatment

Treatment of advanced cutaneous melanoma is difficult and often notbrings the expected results. Some patients with disseminated melanoma use conventional methods of treatment - chemotherapy with single drugs (decarbazine, temozolomide, nitrosourea derivatives, platinum compounds, taxoids, dye alkaloids, etc.) and with the use of multi-drug programs (CDBT, BOLD, CVD, PC, etc …

Cancer immunotherapy with cytokines (interferon alfa2b, interleukin-2) and anti-CTLA4 monoclonal antibodies (ipilimumab) is also possible, as well as biochemotherapy involving the combination of chemotherapy and immunotherapy.

In the treatment of patients with generalized cutaneous melanoma, experimental therapies for melanoma are also used (patients undergo treatment in controlled clinical trials) and then it may be:

  • study of new cytotoxic drugs (nanoparticle bound paclitaxel, sodium tasisulam, sagopilone, etc.)
  • using old drugs in a new role (e.g. metronomic chemotherapy - an attempt to obtain an anti-angiogenic effect by changing the method of administration)
  • therapy with molecularly targeted drugs (BRAF protein inhibitors, MEK inhibitors, HSP inhibitors, KTI inhibitors, PI3K / Akt / TOR pathway inhibitors, proteasome inhibitors)
  • experimental immunotherapy (active: vaccines, interleukin-12, TNF, tremelimumab, and passive: using TIL, LAK cells)

Czerniak: adjuvant therapy

The clinical guidelines include a number of innovative therapies - immunotherapy and molecularly targeted therapies. The applicability of specific drugs / therapeutic regimens depends on the stage of the melanoma, the presence of the mutation and the line of treatment.

In recent years, adjuvant therapy for melanoma deserves special attention - applying the treatment immediately after resection, and not only after relapse.

The promising results of clinical trials suggest that in the near future systemic adjuvant therapy in patients with high-risk melanoma will be the therapeutic standard.

What exactly is it? Adjuvant therapies are the so-called adjuvants, which are used immediately after surgical treatment to reduce the risk of disease recurrence (local recurrence and distant metastases), which improves the patient's prognosis.

The reduction in the risk of disease recurrence or death after adjuvant therapy in clinical trials ranges from 25% to 51%. There are several alternative adjuvant therapies for which clinical trials have been designed differently. Pembrolizumab, dabrafenib in combination with trametiniband ipilimumab (registered only by the US Food and Drug Administration in this indication) were compared with placebo, while nivolumab - with an active comparator (ipilimumab).

Czerniak: prognosis

Early identification of the primary lesion (biopsy excising the primary lesion) and metastases to regional lymph nodes (sentinel node biopsy) offers a unique opportunity to cure skin melanoma. At the time of diagnosis, skin melanoma is localized in about 80 percent of patients, regional in 15 percent, and generalization in 5 percent of patients.

Unfortunately, the progress in adjuvant and palliative treatment in patients with generalized cutaneous melanoma is still unsatisfactory. The 5-year survival rates are 60-90 percent in early melanoma, 20-70 percent in the regional stage and 5-10 percent in the generalized stage.

The prognosis is negatively influenced by: the thickness of the infiltration - the risk of recurrence and unfavorable prognosis increases with every millimeter of the infiltration depth of the primary melanoma and the appearance of ulceration at the site of the primary melanoma. Increased concentration of LDH (lactate dehydrogenase) in patients with diagnosed dissemination is a very unfavorable prognostic factor, regardless of the number and location of metastatic lesions.

In Poland, almost 1/3 of melanoma patients die

- In Australia, almost 8-10 times more people suffer from melanoma than in Poland, but the same number of people die. There it is detected much earlier. Australians know that you should watch your skin and report to the doctor much earlier - says the news agency Newseria Piotr Rutkowski, oncologist surgeon, head of the Department of Soft Tissue, Bone and Melanoma Tumors at the Oncology Center - Institute of Maria Skłodowskiej-Curie in Warsaw, chairman of the Scientific Council of the Czerniak Academy at the Polish Society of Oncological Surgery. - 80 percent patients are cured, but it's still worse than in Germany or the United States, because we are starting from a worse point - with an average thickness of 1.8 mm, and in the United States and Germany, the average thickness is 0.8 mm. This makes our results worse.

Source: lifestyle.newseria.pl

Worth knowing

How to avoid melanoma?

Advises prof. Lidia Rudnicka, head of the Dermatology Clinic of the Ministry of Interior and Administration in Warsaw.

  • Do the clothes protect against radiation?

Yes, but only up to a point. It is enough to watch them against the light. The translucent fabric lets rays through. It is considered thatclothing protects like a filter 15. So it is not enough just to cover up, although it is very necessary.

  • What birthmarks should make us visit a dermatologist?

Birthmarks that grow rapidly. They are over 6 mm in diameter, irregular, asymmetrical in shape, with uneven edges. They change color: from gray-brown to black. Most often, melanoma is dark brown or black, but skin-colored melanoma happens, and this is the most dangerous, because it is noticed and recognized at the latest.

  • Does melanoma occur only at the site of moles?

Most often. But it can also develop on smooth skin. It can also arise inside the body, wherever there are melanocytes, i.e. cells that produce the skin pigment, melanin. They are also found on the mucous membranes of the genital organs and the mouth. Melanocytes, which can make them malignant, are also on the eyeball, so don't forget to wear sunscreen.

  • Do we always remove a disturbing birthmark?

We remove moles exposed to constant irritation as a preventive measure: on the scalp, feet and around the genitals. If we suspect melanoma, we remove it quickly.

  • Is the mole removal procedure complicated?

It lasts about 30 minutes, it is done under local anesthesia and then you can return to your daily duties. Up to three birthmarks are removed at once.

  • There is always a scar after removing a mole?

The wound on the face, neckline, back of the hand is closed with glue or a so-called strip. After the procedure, there is almost no trace of it. The scar stays where the sutures are applied (on thicker skin that becomes tight).

  • Do we also risk melanoma when using the solarium?

Yes, even more than sunbathing without sunscreen. The World He alth Organization has made recommendations for those who use the tanning bed. First of all, this method of tanning is only for he althy people. Secondly, the WHO proposes that it should be avoided by people with very fair skin, numerous pigmented skin marks, and lots of freckles. It is also important to properly prepare the skin: intensely moisturize it. Experts ultimately propose that we should not spend more than 23-30 minutes in the solarium a year!

  • Skin tests - how often?

He althy people under the age of 40 who do not have moles should have their skin tested every three years. Older every year. Conversely, ifsomeone has a lot of birthmarks, they should be checked every three months. You have to watch for yourself whether they grow, change shape and color. If we notice something like this, we should always show the changing birthmarks to the doctor. Preferably a dermatologist.

Category:

Dermatology