Introduction to melanoma

Introduction:

MelanomaIt is a common skin tumor caused by abnormal hyperplasia of melanocytes, which is extremely malignant and accounts for a large part of skin tumor deaths. Most occur in the skin or near the skin of the mucous membrane, also seen in the pia mater and choroid. The incidence rate varies according to race, region and ethnicity. The incidence of white people is much higher than that of black people. The incidence of white people living in Queensland, Australia is as high as 17/100,000. Although China is a low-incidence area of melanoma, the incidence rate has been rising in recent years.

Cause:

(1) Causes of the disease

Melanoma can be composed of epidermal melanocytes, sputum cells or dermis into melanocytes. The tumor originates from the neural crest of the ectoderm. The melanocytes are arranged between the epidermis and the basal cells. After the cells produce pigment, the melanin particles are transported into the basal cells and hair through the dendrites. Most malignant melanomas occur because melanin 痣 is repeatedly muffled, grabbed and damaged, causing malignant transformation, inappropriate excavation and drug corrosion, which can convert benign melanin into malignant melanoma. Women during pregnancy or childbearing age can develop malignant melanoma rapidly, suggesting that the disease is associated with endocrine. In terms of age, it occurs mostly in middle-aged and elderly people, and very few occur before puberty. According to reports: 84% of malignant melanoma comes from benign sputum. According to Wieeio, many patients were not noticed at the beginning of the illness because of their small size. Some people think that benign sputum is the biggest source of malignant melanoma.

Chinese medicine believes that: malignant melanoma occurs due to the wind and evil in the blood, change; or the blood of the veins, stagnation in the Wei, the yang qi bundle formed; the kidney in the turbid gas mixed with the yang, yang caused by the convergence, It is related to factors such as blood clotting and stagnation.

The true cause of normal melanocytoma is unclear and may be related to the following factors:

(1) Air pollution Frequent emissions of harmful substances such as Freon destroy the ozone layer, causing insufficient UV filtration. Harmful ultraviolet rays and harmful substances in the air work together on human skin, causing abnormal expression of melanocytes and triggering melanin. tumor.

(2) Aiming at the heart of beauty Many people use chemical cosmetics in order to purify the skin, causing chemical skin pollution. Some people even use chemical etchants to remove the black sputum on the skin. The result is counterproductive and stimulates melanocytes. Excessive proliferation.

(3) Lack of health knowledge The black cockroaches that are prone to friction in the foot and perineum are not given enough attention. Due to their long-term compression and friction, they will eventually undergo a malignant transformation.

(4) Abuse of estrogen drugs has found that estrogen receptors are present in cells of malignant melanoma. Therefore, it is suspected that excessive estrogen may stimulate melanoma.

(5) Impaired defects With the improvement of living standards, the life expectancy of Chinese people is significantly prolonged. With the increase of age, the body's immune function is gradually declining. The study found that low immune function is one of the important causes of melanoma, so the incidence of melanoma in the elderly is very high.

(6) Benign melanin plaques are black sputum, in which the border sputum is most likely to be malignant, mixed sputum is less, and endothelium is rarely malignant. However, most of the scalp melanoma is not changed from black sputum, so some people think that this disease is not completely related to black sputum.

(7) Ethnic whites have a higher incidence than colored people. For example, the annual incidence rate of Caucasians in the United States is as high as 42/100,000, while that of blacks is only 0.8/100,000.

(two) pathogenesis

Most of the lesions occur at the junction of the dermis and the epidermis. The tumor cells resemble sputum cells, but they are obviously heteromorphic. The interstitial cells and cells are filled with melanin. According to the different cell morphology and melanin content, it can be divided into 5 types:

1. Large epithelioid cells are more common, and the cells are polygonal.

2. Small epithelioid-like nuclei are large and not typical.

3. The cytoplasm of spindle cells is fibrilla-like, with large nuclear staining.

4. The deformed cells are mononuclear or multinuclear.

5. Dendritic cells are larger than normal melanocytes, and the nucleus is abnormal. The tumor cells are strongly positive for casein. When the melanin is small, it is difficult to confirm in HE slices, so it is called "no melanin melanoma", but if With silver staining, melanin can still be detected in a small number of cells.

symptom:

Melanoma occurs in middle-aged and older people, with more men than women. The lower limbs are good, followed by the trunk, head and neck and upper limbs. The symptoms are mainly melanin nodules that grow up quickly. At the beginning, melanin deposition can occur in normal skin, or pigmentation occurs in pigmented nevus, darkening in black, followed by lesion damage, increased hardness, accompanied by itching pain. Some of the lesions of melanoma are bulging, plaque and nodular, and some are braided or cauliflower-like. When subcutaneous tissue is grown, it is subcutaneous nodules or masses. When it spreads around, there are stellate dark spots or small nodules. Common manifestations are regional lymph node metastasis of melanoma, and even a regional lymph node enlargement. In the late stage, it is transferred from the bloodstream to the organs of the lungs, liver, bones and brain.

Clinical classification

(1) The superficial spread type is the most common, accounting for about 70%. Occurs in the age of 50, women are more common in the body, men tend to the trunk. Its malignancy is between the freckle type and the nodular type. Early manifestations are brown, brown, blue or black, most of which may be rose red or pink, with jagged edges and a loss of skin texture. The radiation growth period lasts for 1 to 12 years, and less than 5% of lymph node metastasis occurs during this period.

(2) Freckles account for 10% to 15%, which is the lowest of the four types. Occurs in the exposed parts of the head, neck, back of the hand, more common in 60 to 70 years old, more common in women. Clinically, it appears as a large, flat or slightly higher tanned brown-yellow or brown lesion. When the radiation growth is accompanied by vertical growth, the local focal bulge, the color is still brownish yellow, and the lymph node metastasis rate is about 25%.

(3) Nodular type is the type with the highest degree of malignancy in the fourth type, accounting for about 12%. It occurs in the age of 50, and the ratio of male to female is 2:1, which is good for the back. The clinical condition is gray with pink color nodules. When the lesion continues to grow, its color turns blue-black, purple-black jam-like dome-shaped or polyp-like mass, vertical growth is its only growth mode, and the disease progresses rapidly. It lasts for several months to one year, and ulcers and lymph node metastasis occur earlier. This type of prognosis is poor.

(4) Acromoid-like melanoma mainly occurs in the palm, sole and under the skin. The skin lesions in the radiation growth period are brownish yellow, brown or black, not higher than the leather surface. If irregular brown is visible under the nail The yellow or tan stripes extend from the nail bed to the proximal end, and the radiation growth period lasts for about 1 year. If it is not treated in time, it enters the vertical growth phase. The lesions are nodular, the lymph node metastasis rate increases, and the prognosis is also poor.

2. Clinical stage According to the scope of the primary tumor, lymph node metastasis and imaging findings, whether the distant metastasis and other results to estimate the disease.

(1) Stage I: no regional lymph node metastasis.

(2) Stage II: accompanied by regional lymph node metastasis.

(3) Phase III: accompanied by distant metastasis.

In general, if the following changes in pigmented skin lesions often suggest the possibility of early black:

(1) Color variegated is a signal of malignant lesions. Freckles and superficial spreads are often mixed in red or white or blue in brown or black, with blue being even worse.

(2) The edge often has a jagged change, which is caused by the spread of the tumor to the periphery or self-degeneration.

(3) The surface is not smooth, often rough and accompanied by scaly flaky desquamation, when there is bleeding, exudate, can be higher than the leather surface.

(4) The skin around the lesion may have edema or loss of original skin gloss or white or gray.

(5) Itching, local itching, burning or tenderness.

diagnosis:

The diagnosis of melanoma is generally not difficult, and a few atypical cases are confirmed by pathological examination. Indirect immunofluorescence labeling of melanin tissue, dual PAP immunoenzyme labeling assays, and chromogen examination are helpful for diagnosis, and are useful for the diagnosis of "pigment-free" or oligochromic melanoma and for the identification of benign sputum cell tumors and their malignancy.

Identification

The disease should be differentiated from benign borderline tumors, juvenile melanin and cellular blue sputum, and more attention should be paid to the differentiation of basal cell carcinoma. Should also pay attention to the identification of sclerosing hemangioma, senile sputum, seborrheic keratosis, old hematoma under the nail bed.

1. Benign borders are seen as benign large sputum cells, no heterosexual cells, only grow in the dermis, and the inflammatory response is not obvious.

2. Juvenile melanoma is a circular nodule that grows slowly on the face of a child. Microscopically, the cells were pleomorphic and had nuclear division. The tumor cells do not infiltrate into the epidermis, and the surface of the tumor does not form an ulcer.

3. Cellular blue sputum occurs in the buttocks, tail scorpions, and waist, showing a light blue nodule with a smooth and irregular surface. Microscopically, deep black cells and large prismatic cells of dendrites can be seen and assembled into cell islands. When there is a mitotic phase or necrotic area, the possibility of malignant transformation should be considered.

4. Basal cell carcinoma is a malignant tumor of epithelial cells. It is infiltrated deep from the basal layer of the epidermis, and a layer of columnar or cuboid cells surround the cancer nest. Cancer cells stained deeply and did not have a certain arrangement. Cancer cells can contain melanin.

5. Sclerosing hemangioma epidermal hyperkeratosis, dermal papillary proliferation, dilated capillaries are often surrounded by a downwardly extending epidermal process, which looks like an intraepithelial hematoma.

6. The elderly are seen in the sputum on the surface of the elderly. The epidermis is hyperkeratotic, the granules are partially thickened or atrophied, the spinous layer is thick, the base layer is intact, and pigmentation may be increased. The dermal papilla proliferates and its appearance is papillary-like hyperplasia.

7. Seborrheic keratosis lesions also have papillary-like hyperplasia, the lower boundary of the epidermis is clear, the keratinization is incomplete, the granules are thickened first, then thinned or even disappeared, and there may be a small amount or more in the proliferating epidermal cells. melanin.

8. There is a corresponding history of trauma in the hematoma under the nail bed. Microscopically, it is a dry blood cell, which may have epithelial fibroblast proliferation.

complication:

Metastasis can occur in the early stage, and the lungs and brain are more common in the metastatic site. Late stage may be complicated by distant metastasis of lymph nodes and other parts.

treatment:

Western medicine treatment

First, treatment

(1) Surgical treatment

1. Biopsy surgery: For those suspected of malignant melanoma, the lesion should be removed together with the normal skin and subcutaneous fat around 0.5cm~1cm for pathological examination. If it is confirmed to be malignant melanoma, according to its infiltration depth, Decide if you need to add extensive resection. Generally, the biopsy is not taken or clamped, unless the lesion has ulceration, or because the lesion is too large, a resection must cause disfigurement or disability and must be confirmed by pathology, but the closer the biopsy must be connected to the radical surgery. The better. In a prospective analysis, the World Health Organization Collaborating Center for the Diagnosis and Evaluation of Malignant Melanoma believes that excisional biopsy has no adverse effect on prognosis, and biopsy can understand the depth and extent of infiltration of the lesion, which is conducive to the development of a more reasonable and appropriate surgical plan. .

2. The scope of primary lesion resection: The old view advocates that 5 cm of normal skin must have been discarded when the lesion is removed. Most tumor-extra-scientific scientists have a thickness of ≤1mm for thin lesions and only 1cm for normal skin outside the tumor. For patients with a lesion thickness of more than 1mm, they should be extensively resected from 3cm to 5cm from the edge of the tumor. Malignant melanoma located at the extremity often requires a finger-to-finger technique.

3. Regional lymph node dissection

(1) Indications: Most tumor surgeons in the United States hold the following treatment attitudes: 1 The lesion thickness is less than 1 mm, the metastatic rate is very low, and prophylactic lymphadenectomy cannot be expected to change the long-term prognosis; 2 lesion thickness > 3.5 cm ~4mm is more likely to have distant occult metastasis, and the long-term survival rate is relatively low (20% to 30%). Even if preventive lymph node dissection is performed, it is difficult to achieve a meaningful improvement in survival rate. . Despite this, it is advocated that as long as there is no distant metastases to be investigated, there should be many people who should be treated with prophylactic lymph node dissection; 3 lesions with thickness between the above two types, the occult lymph node metastasis rate is quite high, is to prevent Sexual lymph node dissection is expected to improve the best survival factor.

(2) Range of regional lymph node dissection: When the head and neck malignant melanoma is used for cervical lymph node dissection, the primary lesion located on the face should focus on clearing the parotid gland, the infraorbital and submandibular triangle lymph nodes; if the lesion is located in the occipital region, the focus is cleared. Lymph nodes in the posterior triangle of the neck. Malignant melanoma occurring in the upper extremity requires axillary lymph node dissection, and in the lower extremities should be performed in the inguinal or inguinal lymph node dissection. Malignant melanoma occurring in the chest and abdomen is treated as ipsilateral axillary or inguinal lymph node dissection.

4. Palliative resection: For those who are not suitable for radical surgery, such as large lesions with distant metastasis, in order to relieve ulcer bleeding or pain, as long as the anatomical conditions permit, debulking or palliative resection may be considered.

(B) Radiation therapy In addition to some very early freckle-type malignant melanoma is effective for radiation therapy, it is generally not effective for other primary tumors. Therefore, radiotherapy is generally not used for the primary tumor, but radiotherapy is used for the metastatic lesion. At present, the commonly used radiation dose is: superficial lymph nodes, soft tissue and metastases in the thoracic cavity, abdominal cavity and pelvic cavity. Each exposure amount is ≥500cCy, twice a week, the total amount is 2000~4000cCy, and the bone metastasis is 200~400cCy each time. The total amount is more than 3000cCy.

(three) chemotherapy

Single medication

(1) nitrosourea drugs: have a certain effect on melanoma. A comprehensive literature report, BCNU treatment of 122 cases of melanoma, the effective rate was 18%, MeCCNU treatment of 108 cases, the effective rate of 17%, CCNU treatment of 133 cases, the effective rate of 13%.

(2) Nitrienamide (DTIC): Due to the emergence of DTIC, the treatment of melanoma has been advanced one step further and has become the most widely used drug. GaiIanl reported that DTIC had the best efficacy, treating 28 cases of melanoma, each dose was 350mg/m2, for 6 days, 28 days for a course of treatment, the effective rate was 35%.

2. Combination therapy: Malignant melanoma is not very sensitive to chemotherapy, but the combination can improve the efficiency and reduce the toxicity. The commonly used combination chemotherapy is as follows:

(1) DAV regimen (DTIc, ACNu, VCR) is the preferred chemotherapy regimen for melanoma. Medication method: DTIcloo ~ 200mg, iv d1 ~ 5ACNUl00mgiv d1VCR 2mg iv d1, repeated once every 21 days.

(2) DDBT program (DTIC, DDP, BCNU, TAM) Usage: DTIC 220mg/m2, intravenous d1～3/3w, DDP 25mg/m2, intravenous drip d1～3w, BCNUl50mg/m2, intravenous d1/6w, TAM10mgPO , 2/d. The effective rate is 52.5%.

(3) CBD program (CCNU, BLM, DDP) Usage: CCNU 80mg/m2, oral, d1/6w, BLMl5u/m2, intravenous d3~7/6w, DDP 40mg/m2, intravenous d8/6w. The efficiency is 48%.

(4) Immunotherapy for the self-reduction of malignant melanoma, indicating that it is related to the immune function of the body.BCG(BCG) can concentrate lymphocytes in melanoma patients in tumor nodules, stimulating patients to produce a strong immune response, in order to achieve tumor treatment. BCG can be used for skin scratching, intratumoral injection, and oral administration. For local small lesions with BCG for intratumoral injection, the effective rate can reach 75% to 90%. In recent years, interferon, interleukin-2 (ILA-2) and lymphokines have been used to activate biological response modifiers such as killer cells (LAK cells), and have achieved certain effects.

The above content is for reference only, please consult the relevant physician or relevant medical institution if necessary.

prevention:

Try to avoid sun exposure. The use of sun screen is an important first-level preventive measure, especially for those at high risk, strengthen the education of the general public and professionals, and improve the early morning, early detection, early diagnosis and early treatment. .

1. For the pigmented nevus that occurs in the easily rubbed area, biopsy should be taken. If the child's big hairs are at the waist, they are often rubbed and squeezed by the belt, and should be removed as soon as possible. If it is difficult to remove all of them at a time, the main part can be removed as much as possible in the middle of the big hairs before the malignant transformation, and the two sides are sutured. After the surrounding skin is loosened, the rest will be removed until all the black sputum is removed to prevent malignant transformation. Specimens must be sent for each resected specimen. If there is malignant transformation, all should be removed and skin grafting should be performed.

2. It is not advisable to stimulate black mites with corrosive drugs or thorough freezing. It is dangerous to repeat it several times without freezing, because black mites often become malignant due to traumatic stimulation. According to reports, some people have become malignant due to incomplete freezing. About 30% to 50% of malignant melanoma is associated with external stimuli. If you need to remove the sputum for cosmetic purposes, it is safe and reliable. Freezing combined with resection, and strive to complete once, should not be divided and resected, the excised specimen should be sent for pathological examination.

3. Colorless information

(1) The color of the color is increased, and the pigment is deep or light.

(2) The color enamel spreads radially to the periphery.

(3) There is no pain or discomfort in the color, and there is a small amount of exudate on the surface.

(4) The lymph nodes in the color sputum area are swollen, and blue and black are faintly visible.

(5) The patient dissolves blue and black urine.

Prognosis

The recurrence and metastasis rates of melanoma are high and the prognosis is poor. Factors affecting prognosis include:

1. Relative to tumor infiltration depth According to the World Health Organization's follow-up of a group of malignant melanin, the prognosis is closely related to tumor thickness. For patients with tumor ≤0.75mm, the 5-year survival rate was 89%, and ≥4mm was only 25%.

2. Lymph node metastasis The 5-year survival rate was 77% in patients without lymph node metastasis, and only 31% in patients with lymph node metastasis. Survival is also related to the amount of lymph node metastasis.

3. The location of malignant melanoma in the lesion site is related to prognosis. The prognosis occurred in the trunk, with a 5-year survival rate of 41%; the second in the head, the 5-year survival rate was 53%; the limbs were better, the lower limbs had a 5-year survival rate of 57%, and the upper limbs were 60%. %; the prognosis of melanoma occurring in the mucosa is even worse.

4. Age and gender generally believe that female patients are significantly better than males, and younger ones are better than older ones.

5. The surgical method, that is, the thickness of the tumor is related to the extent of resection, the thickness is ≤0.75mm, the resection range is 2~3cm away from the edge of the tumor; >4mm is extensive resection within 5cm from the edge of the tumor. Regional lymph node dissection that does not meet the specifications often promotes tumor spread to the whole body and affects prognosis.