Skin melanoma: stages, symptoms, photos, diagnosis and treatment

There are several classifications of malignant melanoma, which allows for a more thorough and differentiated approach to diagnosis and treatment. There are no perfect classifications - when new properties of a tumor are identified, new opportunities for predicting cancer are discovered, so even the most “convenient” and modern systems are updated and supplemented.

Fundamental amendments to the classification of melanomas by stage were made in 2010. They were recommended by the American Joint Commission on Cancer (AJCC) through the joint efforts of cancer centers from different countries. Data on melanoma began to include an accurate diagnosis and prognosis of the disease.

Previously, very thin tumors were classified according to Clark's level of invasion - the number of layers of skin penetrated by the tumor.

Melanoma statistics

Melanoma is the leading type of cancer, ranking third in prevalence in men and second in women. At the same time, the number of victims increases every year, and the disease becomes “younger.”

In most cases, tumors occur on exposed skin, with about 70% of cases on the face.

Modern medicine has a wide range of cancer treatment options. Oncologists have chemotherapy, hormonal treatment, immunotherapy, which allows them to block specific immune checkpoints, and targeted drugs, which specifically affect cancer target cells. Recovery is possible, the main thing is timely diagnosis!

MelanomaUnit oncologists recommend regular preventive examinations and medical examinations for early diagnosis of melanoma and other skin cancers.

Diagnostic imaging of melanoma

The main principle of successful treatment of melanoma is early diagnosis - the earlier the tumor is found, the higher the patient’s chances of a full recovery or at least a significant prolongation of life. Thus, the five-year survival rate for patients with melanoma in stage 0 is 97%, in stage IV - about 10%. Therefore, both the doctor and the cosmetologist must take an extremely responsible approach to the examination of any skin formations.

In addition to visual observation of the tumor and traditional dermatoscopy, today there are powerful technical solutions based on artificial intelligence. They allow not only to diagnose minimal pathological changes in healthy tissues, but also to examine the entire body in dynamics - the FotoFinder digital complex (FotoFinder Systems GmbH) has such capabilities.

FotoFinder complex with automatic body mapping

FotoFinder can have different configurations, but most often it consists of a high-resolution camera, a robotic tripod, a laser pointer, a digital video dermatoscope and a computer with a set of special programs.

The medicam 1000 digital video dermatoscope is used for targeted examination of suspicious neoplasms and recording the results, linking them to a specific patient. The medicam 1000 features a range of patented technologies, such as FullHD CrystallVew for superior image quality, up to 140x image magnification, and special accessories for fluorescence diagnostics and capillaroscopy. Together with convenient image sorting and quick search, this ensures high-quality and early diagnosis of melanoma and successful treatment methods for skin melanoma and other neoplasms.

The ATBM (Automatic Total Body Mapping) system includes a camera, a robotic tripod and a laser pointer. Using a laser pointer, the operator (both the doctor and the nursing staff) sets the tripod at the recommended distance between the camera and the patient. Next, a guide program opens on the computer - it tells the operator what position the patient should take for filming.

To reproduce poses as accurately as possible, Ghost technology is used - the monitor displays a “ghost-contour” of the first photograph of a person, which must be adhered to in order to obtain uniformity in all subsequent photographs. The operator sees exactly where the patient does not fall into the circuit, and can guide him with the words “raise your right arm a little higher,” “straighten your back,” and so on. The shooting itself is carried out in semi-automatic mode, which also ensures uniform results.

The result is 20 standard images, each of which is analyzed by Bodyscan module for dynamic changes. It records all tumors of a given patient, assigning them a unique index. During subsequent acquisitions, Bodyscan detects changes and highlights them to attract the physician's attention. In addition to preliminary analysis, Bodyscan has extensive capabilities for sorting and end-to-end image search, helping the doctor create a convenient database of images of his patients.

The Moleanalyser pro software package with artificial intelligence specifically examines micrographs of suspicious tumors. This complex was pre-trained on hundreds of thousands of photographs with confirmed diagnoses, which allows it to detect melanoma and other malignant skin tumors with an accuracy of 95%. As a result, the doctor receives a personal self-learning assistant who has a huge knowledge base and does not miss a single point on the patient’s body. In turn, the patient receives a guarantee of a truly high-quality early diagnosis of melanoma, which increases his chances of successful treatment.

Mobile dermatoscopy and telemedicine Handyscope

A simpler alternative to the FotoFinder complex is mobile dermatoscopy and telemedicine Handyscope . Handyscope is a small device that is installed on the iPhone camera, as well as a special application for this smartphone. The doctor gets ample opportunities for immersion and polarization dermatoscopy, precise image capture and freezing, 20x optical zoom and the highest image quality thanks to the powerful iPhone camera.

The Handyscope 3 application is installed on the iPhone and works in conjunction with the Handyscope device. The application allows you to quickly take pictures of tumors, store them in a convenient database, and request their assessment using artificial intelligence or a third-party specialist. In the latter case, the Second Opinion Service - telemedicine to communicate with dermatologists and histologists around the world. Now you can get advice from leading experts for the most accurate diagnosis and choice of treatment method for skin melanoma.

How does melanoma manifest?

Melanoma is one of the fastest growing types of cancer, which quickly “gives” metastases to the lymph nodes and internal organs.

At the initial stage of skin cancer, attention is drawn to the appearance of a new growth on the skin or a change in the color, size and shape of an existing mole.

The patient may also complain of itching, pain and burning sensation in the area of formation.

Mitotic index

Mitosis

- the process of cell division (cell reproduction). Mitotic activity (mitotic index) is determined under a microscope as the percentage of dividing cells from 1000 cells of the specimen (tumor).

The presence of mitoses demonstrates the growth and activity of the tumor, and also gives a certain prognosis for the development of the disease.

The American Joint Committee on Cancer has added mitotic rate to its clinical diagnostic protocol. The mitotic index in melanoma was introduced into the scoring system on the basis that this indicator is an independent factor determining prognosis.

The mitotic rate replaced another index - the Clark penetration level for melanomas, stage T1.

By classifying tumor mutations, cancer aggressiveness can be more accurately assessed.

The presence of at least one mitosis per 1 mm² may advance thin melanoma to a more advanced stage with a high risk of developing metastases.

The classification of melanoma according to Breslow and Clark loses all meaning when distant metastases appear. Stage IV advanced melanoma, regardless of the degree of invasion and the thickness of the primary tumor substrate, is a special form of cancer for which radical treatment is not possible.

One of the main techniques that allows specialists from different countries to “communicate in the same language” is the pTNM system. It is used as an international classification of the stages of all malignant diseases. The TNM classification of melanoma describes in as much detail as possible the morphological changes of the tumor in accordance with the stage of tumor growth. For this purpose, the following evaluation criteria are used:

T – tumor – “tumor” refers to the degree of the primary tumor N – nodus – “node” the absence or presence of a degree of regional metastasis to the lymph nodes M – metastasis – “metastases” the absence or presence of distant metastases

The TNM classification distinguishes between a clinical classification (TNM) and a pathological classification (rTNM). TNM stage is determined after tumor removal.

ABCDE method in diagnosing melanoma

There are criteria (ABCDE), thanks to which patients can independently suspect a problem and consult a doctor:

A (asymmetry) – asymmetry . The mole grows unevenly to the side. Normally, if you draw an imaginary line through the middle of the mole, the halves will be symmetrical.
B (border irregularity) – uneven, jagged, fuzzy edge.
C (color) – color. Suspicion of melanoma is caused by changes or heterogeneity in color, the appearance of inclusions.
D (diameter) – diameter. Increase in size of a common mole.
E (evolving) – variability of any characteristic: color, shape, size is a reason for immediate consultation with an experienced dermato-oncologist.

IMPORTANT : there is a type of melanoma that contains virtually no pigment and in the initial stages resembles more of a pimple or an ingrown hair, this disease is called non-pigmented melanoma .

There are several successive stages in the development of melanoma:

Stage O - characterized by damage to the upper layers of the epithelium, which responds well to treatment.
Stage 1 - the pathological process penetrates into the deeper layers of the epithelium, but the size of the tumor does not exceed 2 cm.
Stage 2 - the size of the tumor can increase up to 5 cm.
Stage 3 - characterized by the appearance of the first metastases in sentinel and regional lymph nodes.
Stage 4 is the terminal stage of the disease, which is characterized by multiple metastases to distant organs and tissues.

Clinical classification. Types of melanoma

Melanoma manifests itself in various forms, there are 3 main types:

Superficially widespread.

Tumor of melanocytic origin. The most common disease (70 to 75% of cases) among middle-aged Caucasians. Relatively small, complex in shape with uneven edges. The color is uneven, reddish-brown or brown, with small patches of bluish tint. The neoplasm tends to become a tissue defect, accompanied by discharge (usually bloody). Growth is possible both on the surface and in depth. The transition to the vertical growth phase can take months or even years.

What types of melanoma are there?

There are several classifications of melanoma, the most common of which is the TNM system:

Tumor
LymphNode – lymph node
Metastasis – metastases

T-category

This is the volume or thickness of the tumor, which is measured using the Breslow system. Also in this category the rate of development of metastases is taken into account.

N-category

Determines the presence of a tumor in the lymph nodes that are susceptible to metastasis in the first place.

M-category

This category determines the spread of the pathological process to internal organs.

Classification according to criterion M (presence of distant metastases)

As we have already said, all metastases that extend beyond the zone of regional lymph nodes or affect internal organs are distant. Here are the following options:

M0 - no distant metastases.
M1 - there are distant metastases. In this case, this stage is divided into the following substages: M1a - there is metastatic damage to the skin, subcutaneous tissue and lymph nodes (not regional) with a normal level of lactate dehydrogenase (LDH).
M1b - melanoma metastases affect the lungs, LDH levels are normal.
M1c - there are metastases to other internal organs, or metastases to the skin, subcutaneous tissue or lymph nodes with elevated LDH levels.

Stages of melanoma

Stages of melanoma	Characteristics of the stage
Melanoma 0	Present only in the upper layer of the skin - the epidermis (in situ). This melanoma is non-invasive; it does not penetrate into the deeper layers of the skin and does not spread to other parts of the body.
Melanoma I	There are two subcategories here - A and B. The thickness of the tumor at an early stage does not exceed 1 mm. The neoplasm has no peeling or ulcers and does not bleed. The rate of cell division is quite low. Melanoma does not affect organs or lymph nodes. At this stage, surgery is recommended, i.e., surgical removal of the malignant neoplasm.
Melanoma II	There are three subcategories here - A, B and C. At this stage, the tumor penetrates deeper. The thickness of melanoma can reach 2.00 mm and sometimes 4.00 mm. The surface of the melanoma itself takes on a hypertrophied appearance. There is peeling, the presence of ulcers, and sometimes bleeding. Lymph nodes and other organs are not affected.
Melanoma III	There are also three subcategories here - A, B and C. At this stage, the tumor affects the lymph nodes. They can be increased, but not always. The malignant neoplasm thickens and penetrates even deeper into the tissue. Expressions can also either appear or not. At this stage, radiation and operable (surgical) methods are accepted as treatment.
Melanoma IV	This stage is the last stage of skin cancer. The malignant neoplasm is already metastasizing, affecting internal organs such as the liver, lungs, and brain. Penetrates to distant lymph nodes and affects individual areas of the skin. At this stage, long-term and complex treatment is necessary. It is also possible to resort to surgical methods, removing individual skin lesions affected by the tumor or cutting out metastases from internal organs.

Classification of melanoma according to Clark

Clark's levels of melanoma invasion reflect the extent to which the tumor has invaded the skin structure. There are five levels of tumors:

I
– all tumor cells are located within the epidermal layer, without growing into the basement membrane, which makes it possible to diagnose “melanoma in situ”;
II
– the basement membrane separating the epidermis and dermis is destroyed by tumor cells, which begin to grow into the upper, papillary layer of the dermis;
III
– the papillary layer is entirely filled with atypical melanocytes, but they are not observed in the reticular layer;
IV
– melanoma cells penetrate into the reticular layer of the dermis;
V
– the growth of tumor cells is already observed in the subcutaneous fatty tissue.

The Clark level is now considered only in rare cases when the mitotic index cannot be determined.

Tumor thickness and mutation classification

In the newest classification of melanoma, Clark levels have much less significance. The most important factors in the new system are:

tumor thickness, known as Breslow thickness (also called Breslow depth);
the appearance of microscopic ulcerations, meaning that the epidermis covering most of the melanoma is not intact;
mitosis rate - the rate of cell division (an indicator of how quickly cancer cells grow).

Diagnosis of melanoma

The prognosis for recovery largely depends on the timeliness of diagnosis and the prescription of adequate treatment.

Early accurate diagnosis of melanoma is carried out using an accurate modern examination - dermatoscopy .

The tumor can be diagnosed with high accuracy using special studies: dermatoscopy, drawing up a “mole map” using the Fotofinder system.

At the moment, no single cause of melanoma has been established, but doctors identify a number of predisposing factors :

excessive inhalation or active exposure of the skin to the sun's rays
heredity
a certain phototype - freckles, light skin and eye color
a large number of moles (nevi) on the body.

If you are at risk, it is recommended not to overuse ultraviolet rays (tanning, solarium). In people with dark hair and dark skin tone, melanomas may form on the surfaces of the palms and soles. Many clinical studies have proven that 50-75% of melanomas are formed from moles already on the body. Accidental damage can cause it to transform into a malignant tumor. Therefore, it is recommended to take special care to protect nevi from external trauma, rubbing, and to visit an oncologist at the first warning signs, which include:

horizontal or vertical unnatural growth;
identified asymmetry of the edges;
growths on a mole;
mole falling off;
color changes;
discomfort in the area of the nevus;
the appearance of foreign formations on the mole, bleeding.
sunburn, intense tanning both naturally and in a solarium
congenital nevi
genetic predisposition , that is, cases of cancer, especially skin cancer, in close relatives
diseases of the endocrine system, especially damage to the thyroid gland
trauma to the skin , birthmarks and moles
increased sensitivity to ultraviolet radiation
age factor – with age increases the risk of skin cancer
Skin phenotypes 1 and 2 are people with fair skin, blond or red hair, blue or gray eyes and freckles.

Melanoma cancer cells spread throughout the body through the lymphatic system, and one of the earliest sites of spread for metastasis is nearby lymph nodes. Examination of the lymph nodes helps answer the question of whether melanoma has metastasized to other parts of the body.

Professor Chaim Gutman, doctor of the highest category

For more information about the causes and risk factors for melanoma, see the article “Risk Factors for Melanoma”

The first signs of melanoma

Melanoma is the acquisition by cells of unfavorable signs of malignancy (malignancy properties), expressed by various symptoms.

To make it easier to remember the signs of melanoma, use the “FIGARO” rule:

Shape – swollen above the surface;

And changes - accelerated growth;

Borders are openwork, irregular, indented;

And symmetry is the absence of mirror similarity between the two halves of the formation;

P size – a formation with a diameter of more than 6 mm is considered a critical value;

About paint - uneven color, inclusion of random spots of black, blue, pink, red.

In widespread practice, the English version is also popular, summarizing the main, most typical features - the “ABCDE rule”:

A symmetry is an asymmetry in which, if you draw an imaginary line dividing the formation in half, one half will not be similar to the other.

B order irregularity – the edge is uneven, scalloped.

Color is a color that is different from other pigment formations. Interspersed areas of blue, white, and red colors are possible.

D iameter – diameter. Any lesion larger than 6 mm requires additional observation.

E volution – variability, development: density, structure, size.

Without special studies, it is difficult to determine the type of nevus, but timely changes in the nature of the spot will help detect malignancy.

Melanoma staging

Staging of melanoma or, in other words, determining the stage of tumor development is based on its thickness, size, rate of spread of metastases, presentation of the tumor (how often and severely symptoms manifest itself), damage to the lymph nodes, as well as other organs.

To determine the stage, it is necessary to conduct a comprehensive examination. It is carried out as follows:

Examination by a dermato-oncologist
Dermatoscopy
Biopsy of the pathological formation followed by histology
If necessary, computed tomography (CT), radiography, ultrasound and magnetic resonance imaging (MRI) may be prescribed.

Determining the stage of melanoma development is extremely important, as this helps to prescribe the most effective treatment and apply the right method in the fight against malignancy.

Melanoma, what is it?

Melanocytes synthesize pigments responsible for coloring the skin, eye color, and hair. Pigmented formations filled with melanin are called moles and can appear throughout life. Certain causative factors of an exogenous (from the Greek “exo” - external) and endogenous (“endo” - internal) nature can cause malignancy of nevi. As a result, areas of the body where there are congenital or acquired nevi are at risk of developing melanoma: the skin, less often the mucous membranes and the retina. The altered cells are able to multiply and grow uncontrollably, forming a tumor and metastasizing. Most often, among benign “brothers”, a single malignant neoplasm is discovered.

The clinical picture is varied. The size, outline, surface, pigmentation, and density of the tumor vary widely. Any changes that occur with a mole should alert you.

How to determine the stage of melanoma

In general, there are two main methods for determining the stages of melanoma.

Clinical – based on an examination of the patient by a specialist and the results of a biopsy (morphological examination of a cell sample).

Histological – based on a microscopic method for studying tissues, organs and body systems, using biopsy and surgical methods. Histological analysis, as a rule, shows a higher stage of development of the malignant neoplasm. So, if a biopsy showed, for example, the 3rd stage of melanoma, then histological analysis may already show the 4th stage of skin cancer.

Melanoma stage	Characteristics of the spread of melanoma
Stage 0	Tis, N0, M0 – the earliest stage. This stage means that the tumor has not spread to the lower layer (dermis). Melanoma is found in the epidermis.
IA stage	T1a, N0, M0 – stage 1A melanoma, malignant neoplasm thinner than 1 mm. This stage means that melanoma has not been diagnosed. The rate of spread of metastases is less than 1/mm2. Melanoma has not yet invaded the lymph nodes or distal organs.
IB stage	T1b or T2a, N0, M0 – stage 1B melanoma, a malignant neoplasm thinner than 1 mm. Melanoma has been identified, the rate of spread of metastases is less than 1/mm2. Also at this stage, melanoma may not be detected, and its thickness can reach from 1.01 to 2.00 mm. At this stage, melanoma has not yet affected the lymph nodes or distal organs.
Stage IIA	T2b or T3a, N0, M0 – stage 2A melanoma. At this stage, the thickness of the melanoma can vary from 1.01 to 2.0 mm, and the neoplasm is identified. Also, the thickness of melanoma can be from 2.01 to 4.00 mm, but the neoplasm is not detected. Melanoma has not yet invaded the lymph nodes or distal organs.
IIB stage	T3b or T4a, N0, M0 – stage 2B melanoma. At this stage, the thickness of melanoma can be from 2.01 to 4.00, and the neoplasm is detected. Also, the thickness of the neoplasm may be more than 4.00 mm, but it is not pronounced. There is no melanoma in distal organs and lymph nodes.
IIC stage	T4b, N0, M0 - stage 2C melanoma. At this stage, the thickness of the melanoma is 4 mm, it is revealed. Melanoma has not yet invaded the lymph nodes or distal organs.
IIIA stage	T1a to T4a, N1a or N2a, M0 . At this stage, the thickness of the melanoma is any, it is not expressed. Melanoma has already spread to 1-3 lymph nodes located next to the area of skin that is affected. However, the nodes have not yet been enlarged. Melanoma is only visible when viewed carefully under a microscope. It has not yet spread to remote areas.
IIIB stage	T1a to T4a, N1b or N2b, M0. The thickness of melanoma is any, it is not expressed. Melanoma has already spread to 1-3 lymph nodes located next to the affected area of the skin. Lymph nodes are enlarged. The melanoma has not yet spread to distant areas. T1a to T4a, N2c, M0. The thickness of melanoma is any, it is not expressed. The melanoma has already spread to nearby small areas of skin or, possibly, to the lymphatic channels located next to the tumor. The nodes themselves, however, do not contain melanoma. The melanoma has not yet spread to distant areas.
IIIC stage	T1b to T4b, N1b or N2b, M0 . Melanoma is diagnosed at this stage; its thickness can be of any size. The zone of spread of melanoma in this case is 1-3 lymph nodes located next to the neoplasm that has affected the skin. There is an increase in lymph nodes. The melanoma has not spread to distant areas. T1b to T4b, N2c, M0. Melanoma was also detected, the thickness was any. In this case, it spreads to the lymphatic channels located next to the tumor and nearby areas of the skin. Lymph nodes are not affected by melanoma. The melanoma also did not spread to distant areas. Any T, N3, M0. In this case, melanoma may or may not be detected; its thickness can also be any. It has already spread to 4, and maybe more, clustered lymph nodes located near the site of the lesion. It can also spread to the lymphatic channels passing next to the tumor and nearby areas of the skin. Lymph nodes are enlarged. There is no spread to more distant areas.
IV stage	Any T, any N, M1(a, b, or c) . At this stage, melanoma has already spread far beyond the area on the skin where it appeared. It also spreads to other organs through nearby lymph nodes. Melanoma can spread to the brain, affecting the liver and lungs. It can affect distant lymph nodes, distant areas of the skin, and subcutaneous tissues. In this case, there is no need to consider the spread of melanoma to nearby lymph nodes, as well as its thickness. But, usually, it is very voluminous and affects the lymph nodes.

Classification

Currently, the staging of cutaneous melanoma (MC) is carried out according to TNM / AJCC (8th edition of the Classification of Malignant Tumors 2022) (Table 1). In accordance with the requirements of this classification, the following criteria should be used to determine the stage:

for primary MC - the thickness of the primary tumor, the presence or absence of its ulceration, the mitotic index (the number of mitoses per 1 mm2 with a tumor thickness of less than 1 mm;
for metastases in regional lymph nodes - the number of affected lymph nodes, the nature of the lesion (macro- / micro-), the presence or absence of ulceration of the primary tumor;
for distant metastases - their localization and LDH level.

TNM - clinical classification

•T—primary tumor. The extent of the primary tumor is classified after excision.

•N - regional lymph nodes. •Nx - insufficient data to assess the condition of the regional lymph nodes, •N0 - no signs of metastases in the regional lymph nodes, •N1 - metastases up to 3 cm in the greatest dimension in any of the regional lymph nodes, •N2 - metastases more than 3 cm in the greatest dimension in any of the regional lymph nodes and/or transit metastases: N2a - metastases more than 3 cm in greatest dimension in any of the regional lymph nodes, N2b - transit metastases, N2c - both types of metastases. Note. Transit metastases include metastases involving the skin or subcutaneous tissue at a distance of more than 2 cm from the tumor and not related to regional lymph nodes.

•M - distant metastases: •Mx - insufficient data to determine distant metastases, •MO - no signs of distant metastases, •M1 - there are distant metastases: M1a - metastases in the skin, or subcutaneous tissue, or in the lymph nodes, outside the regional zone , Mlb - organ metastases.

pTNM - pathohistological classification

•pT—primary tumor. When determining the pT category, the following three histological criteria are taken into account: 1) tumor thickness according to A. Breslow (in mm) in the greatest dimension, 2) level of invasion according to W. Clark, 3) the presence or absence of satellites within 2 cm of the primary tumor. •pTx - insufficient data to assess the primary tumor, •pTO - the primary tumor is not determined, •pTis - melanoma in situ (I level of invasion no W. Clark) (atypical melanocytic hyperplasia, non-invasive malignant tumor), •pT1 - tumor up to 0 thickness .75 mm, infiltrating the papillary layer (II level of invasion according to W. Clark), •pT2 - tumor up to 1.5 mm thick and/or infiltrating the border of the papillary-reticular layer (III level of invasion according to W. Clark). Note. Some researchers conditionally divide patients with level III invasion into two subgroups: 1st - with a tumor thickness of less than 0.76 mm, characterized by a favorable prognosis, and 2nd - with a tumor thickness of more than 0.76 mm, when the threat of developing metastases is much higher.

•pT3 - a tumor up to 4 mm thick and/or infiltrating the reticular layer (IV level of invasion according to W. Clark): pT3 - a tumor up to 3.0 mm thick, pT3b - a tumor up to 4.0 mm thick. •pT4 - a tumor more than 4 mm thick and/or infiltrating the subcutaneous tissue (V level of invasion according to W. Clark) and/or there are satellite(s) within 2 cm of the primary tumor: pT4a - a tumor more than 4 mm thick and/or infiltrating subcutaneous tissue, pT4b - satellite(s) within 2 cm of the primary tumor. Note. In case of discrepancy between tumor thickness and level of invasion, the pT category is determined by the least favorable factor.

•pN - regional lymph nodes. pN categories correspond to N categories. pNO - histological examination usually includes 6 or more regional lymph nodes. •рМ - distant metastases. PM-categories correspond to M-categories. Grouping by stages

Stage I pT1N0MO pT2N0MO Stage II pT3N0MO Stage III pT4N0MO Any pT N1-2MO Stage IV Any pT Any N M1

The main pathological forms of melanomas are:

•superficial spreading (39-75% of cases), •nodular (15-30%), •malignant lentigomelanoma (10-13%), •acral lentigenous melanoma (8%).

The microscopic structure of melanomas is varied, but there are four main types:

•epithelial-like, •spindle cell, •noncellular (or small cell), •mixed cell;

• so-called giant cell variants are rare.

Satellites are islands of tumor cells located in the skin or subcutaneous tissue within a radius of 2 cm from the primary tumor. Transit metastases are those that occur along the lymphatic vessels in the skin or subcutaneous tissue at a distance of more than 2 cm from the primary tumor, but not further than the regional lymph nodes themselves.

Clark's levels of melanoma invasion are determined based on the layer of skin into which the melanoma has invaded.

Levels of melanoma invasion according to Clark (I – V) in relation to normal skin N

Currently, this indicator is not a significant prognostic factor.

Determination of tumor thickness according to Breslow is the most important prognostic factor that determines the tactics of tumor treatment. It consists of measuring the depth of invasion in mm. The thickness of a primary melanoma is measured from the granular layer of the epidermis to the deepest part of the tumor.

Recently, the so-called early melanoma, or low-risk melanoma, which combines melanoma in situ and invasive melanoma up to 1 mm thick (growing depth), has begun to be identified abroad. This attention paid to early melanoma is due to the favorable results of its treatment. In patients with melanoma in situ, the 5-year survival rate is more than 99% of cases; A complete recovery is possible. In patients with a depth of invasion of up to 1 mm, survival is achieved in more than 90% of cases. In patients with intermediate (1.0 – 4.0 mm) and high-risk (more than 4.0 mm) melanomas, even with timely comprehensive treatment, the possibility of relapse and mortality remain high.

Scheme for measuring tumor thickness according to Breslow using an eyepiece micrometer. Measurements are taken from the granular layer of the epidermis to the deepest level of the skin bordering tumor cells or adjacent microsatellites. If the tumor is ulcerated, measurement begins at the base of the ulcer.

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Treatment of melanoma at different stages

The choice of treatment tactics depends on the stage of the disease and the patient’s health status.

It is important to know! Depending on the size of the tumor and clinical signs, the surgeon chooses the optimal treatment tactics. The given example of manipulations can be adjusted based on the individual characteristics of the tumor.

Stage 0 - immunomodulators are prescribed in combination with surgical removal of the tumor.

Stage I - surgery is prescribed in combination with a biopsy of sentinel lymph nodes. Most often, such treatment is supplemented with chemotherapy to consolidate the results.

Stage II - treatment is the same as for the first stage - removal of the tumor and consolidation of the result with chemotherapy and other treatment methods. If metastases are detected in the sentinel lymph nodes, the surgeon excises them.

Stage III - drawing up an individual comprehensive treatment plan, combining surgery, chemotherapy, immunotherapy or targeted therapy.

Stage IV - complex therapy depending on the condition and well-being of the patient, in severe cases - palliative treatment.

After completion of treatment, the patient is recommended to undergo regular examinations to monitor his health and not miss a recurrence of skin cancer.

You can find out the exact cost of melanoma removal and prices for histological examination of the tumor by phone and at the initial appointment at the clinic.

Read more about why laser is unacceptable and the advantages of surgical excision in the article “Scalpel versus laser”

Treatment

Treatment of local local injuries consists of timely detection and surgical intervention. Removal is most often performed under infiltration anesthesia. For excision of large formations, general anesthesia may be used. In addition to malignant tumors, there are a number of pre-melanoma diseases in which the surgical method is indicated.
Local-regional damage. Treatment includes wide-area excision and lymph node dissection of the affected lymph nodes. Types of unresectable, transiently metastatic tumors are subjected to isolated regional chemoperfusion. In certain cases, a combined approach has proven itself to be effective, with additional therapy that stimulates the immune system.
Treatment of distant metastases is performed with monomodal chemotherapy. Certain types of mutations are targeted by targeted drugs.

Statistics and forecasts for melanoma

Every year, about 140 thousand new cases of melanoma are diagnosed worldwide. According to statistics, this type of skin cancer affects women more often, and in every tenth patient a genetic predisposition is “to blame.

In recent years, modern medicine has made a big step forward, giving hope to patients diagnosed with melanoma - when diagnosed at the earliest stage of development and prescribed adequate treatment, recovery occurs in more than 90% of cases.

The age of the patient plays an important role in predicting the outcome of the disease. As a rule, the younger the person, the higher the chances of recovery.

Another interesting factor is that people with fair skin are more likely to suffer from skin cancer. But if a dark-skinned person gets sick, it is believed that his disease will be more severe. Predisposing factors for severe melanoma are chronic diseases and health problems.

Metastases

Metastasis is a complex process in which malignant cells are eliminated from the primary tumor site and colonize lymph nodes, internal organs and tissues. As a result, secondary foci of tumor growth are formed. To implement the process of metastasis, the following mechanisms are necessary:

Changes in the surface of malignant cells.
Increased mobility of malignant cells.
The ability for adhesion - attachment to a new place.
Activation of mechanisms for selecting tumor cells with high metastatic potential.
Entry of individual malignant cells or their conglomerates into the lumens of blood or lymphatic vessels and their transportation.
Secondary invasion of vascular endothelium and release of malignant cells from the vascular bed.
Infiltration of surrounding tissues.

If we talk about melanoma, metastases are often detected already in the first year after diagnosis of the disease, including after radical removal of the tumor. With an increase in the interval of relapse-free survival, the likelihood of metastases decreases and reaches a minimum after 7 years from the moment of radical treatment. However, there are cases of late metastasis of melanoma, when secondary lesions were discovered after 10 years or more. Cases of the formation of metastases have also been described 25 years after radical surgery.

Benefits of skin cancer treatment at MelanomaUnit

MelanomaUnit is a branch of an Israeli medical center, the basic principles of which are the highest quality of services, experienced specialists and maximum comfort for patients.

We use equipment from the best manufacturers of medical equipment, certified time-tested drugs and innovative technologies aimed at maintaining health.

Our specialists constantly improve their skills by undergoing training in Russia and abroad. MelanomaUnit doctor is to achieve the best result for the patient.

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Types of melanoma metastases

Melanoma metastasizes in several ways:

lymphogenous;
hematogenous;

Lymphogenic metastasis of melanoma manifests itself as an increase in the size of regional (located near the melanoma) lymph nodes, and then, as the process progresses, distant lymph nodes also increase.

In addition, patients begin to complain of weakness, weight loss, frequent colds, anemia, fever, and night sweats.

With hematogenous metastasis of melanoma (through blood vessels), the liver, lungs, brain and bones are most often affected.

Melanoma metastases to the liver - increased liver size, jaundice, heaviness in the right hypochondrium, bitterness in the mouth, loss of appetite.

In the presence of metastases in the lungs, complaints of a constant cough with mucous or mucopurulent sputum, shortness of breath, frequent pneumonia (patients who repeatedly experience pneumonia within a year must be examined for primary lung cancer), and hemoptysis are typical.

Metastasis of melanoma to the brain is manifested by headaches, blurred vision, nausea and other neurological symptoms, the manifestations of which depend on the location and number of secondary tumors.

Metastases of melanoma to the bone lead to local pain, destruction of bone tissue, and fractures.

Diagnostics

Necessary diagnostic measures when detecting melanoma metastases:

examination of the skin, and not just the area with suspected melanoma.
palpation of all lymph nodes; if a neoplasm is suspected, perform a puncture biopsy.
chest x-ray.
Ultrasound of the abdominal organs.
cytological examination of fingerprint smears in ulcerated tumors.
excisional biopsy with urgent intraoperative histological examination. During an excisional biopsy, the tumor is completely excised, 2-10 mm are removed from its edges and sent for histology.
CT scan of the brain.
osteoscintigraphy.

Differences between melanoma and mole

There are a number of characteristic signs of melanoma that are characteristic of a malignant tumor. During degeneration, the mole changes its shape and loses its symmetry. To check whether melanoma can be benign, draw a conditional line in the middle of the nevus. Benign tumors are completely symmetrical.

The difference between a mole and melanoma is that healthy nevi have clear, even edges. This is due to the local location of melanocytes. If the process of transformation of a mole into melanoma begins, melanocytes begin to spread into neighboring tissues. This leads to a kind of “blurring” of the contour.

Normally, the nevus is uniformly colored with pigment. Birthmarks may contain areas of different shades of the same color, but this is the exception rather than the rule. Usually, due to the uniform distribution of melanocytes in the neoplasm tissue, nevi are colored evenly over the entire area. During degeneration, the cells begin to be distributed unevenly. This leads to the appearance of areas with different colors.

Regular moles do not increase in size. Slight growth may occur during puberty and between the ages of 20 and 30. If a mole begins to grow rapidly, this is an alarming symptom that may appear as it degenerates into melanoma. If you have a mole with a diameter greater than 6 mm, you should immediately undergo examination by a dermatologist.

Relapse and treatment tactics

The risk of relapse depends on the degree of tumor germination and the presence of metastases. Most often, recurrent melanoma is localized near the previous lesion. In order to reduce the risk of tumor recurrence, doctors recommend following the following preventive measures:

limit the time spent under ultraviolet rays;
Conduct regular self-examination of moles;
use protective clothing when in contact with toxic substances;
undergo a preventive examination by a dermatologist.

If you suspect the presence of skin tumors, we recommend that you contact the doctors at the Yusupov Hospital. The clinic’s specialists use modern equipment to diagnose diseases. Therapy is carried out in accordance with the latest global oncological recommendations. You can make an appointment by phone.

First symptoms and signs

Among the main clinical signs of skin cancer are:

pain syndrome. The degree of its severity depends on the stage of development of melanoma. This may include tingling, burning, itching. The symptom is caused by rapid cell division within the tumor;
alopecia in the area of tumor growth. As melanoma grows, the hair follicle is damaged. As a result, hair falls out;
change in the color and contours of the mole. After trauma, the nevus may darken or lighten. The color depends on the degree of melanocyte damage;
rapid growth of the tumor. Melanoma is characterized by rapid growth. This is due to the high aggressiveness of the tumor;
changes in the skin in the area of cancer formation. This symptom is characteristic of the later stages of melanoma development. The skin becomes deformed due to damage to healthy cells;
hyperemia of the tumor contours. The symptom is caused by an inflammatory process. The appearance of this symptom indicates an immune response to the changes taking place;
damage to neighboring organs. Melanoma metastasizes early. Depending on their location, certain symptoms appear. The liver, bones, brain, lungs and gastrointestinal organs are most often affected;
lymphadenopathy. As the tumor process grows, nearby lymph nodes are affected;
lack of appetite. The result is sudden weight loss. As the tumor process spreads, cachexia develops;
intoxication syndrome. It is characterized by weakness, a sharp loss of strength, fluctuations in body temperature, headache and dizziness.

Melanoma with metastases: treatment

Various methods are used to treat metastatic melanomas in modern oncology:

Surgical method

For melanoma with metastases, surgical treatment is possible only in cases where it is necessary to relieve the patient of pathological symptoms, as well as for single tumors of visceral organs with a relatively satisfactory general condition of the patient (for example, with single metastases in the liver or lung).

Sometimes surgical treatment can be used in the presence of single lesions, if antitumor therapy has led to a significant reduction in the volume of the metastatic tumor.

After decades of research, promising therapies have emerged that offer hope of extending patients' lives and, in some cases, even providing a cure. We are talking about immunotherapy and targeted therapy for metastatic tumors.

Immunotherapy

Immunotherapy in oncology is a collective concept that involves the use of a wide arsenal of antitumor drugs:

KEYTRUDA (pembrolizumab), OPDIVO (nivolumab) are designed to block a cellular target known as PD-1, which limits the body's immune system from attacking melanoma cells. When using drugs, the body's immune system's ability to fight metastatic tumor tissue increases.

YERVOY (ipilimumab) is an anti-CTLA-4 monoclonal antibody to restore and strengthen the immune system by supporting T cell activation and proliferation.

PROLEKIN / IL-2 (interleukin-2) is intended to restore and strengthen the immune system. Using the drug shrinks tumors in about 16% of patients, of whom 6% have long-term responses.

IMLYGIC (talimogene laherparepvec "T-Vec") is a genetically modified live oncolytic herpes virus designed to replicate in cancer cells and produce an immune-stimulating protein called GM-CSF (granulocyte-macrophage colony-stimulating factor). 16.3% of patients receiving Imlygic experienced a reduction in the size of secondary skin lesions and lymph nodes.

Targeted therapy

COTELLIC (cobimetinib) and ZELBORAF (vemurafenib) in combination work to inhibit the growth of metastatic melanoma.

MEKINIST (trametinib) and TAFINLAR (dabrafenib) in patients with a BRAF mutation Tafinlar in combination with Trametinib blocks a cellular pathway to inhibit the growth of melanoma metastases. The drugs Braftovi (Encorafenib), Mektovi (Binimetinib) and Erivedge (Vismodegib) work in a similar way.

ZELBORAF (vemurafenib) . The BRAF protein is normally involved in regulating cell growth, but is mutated in about half of patients with advanced melanoma. Vemurafenib and dabrafenib interfere with the function of the V600E mutant BRAF protein gene.