1.What is melanoma?
Human skin is divided into epidermis and dermis. Epidermis is divided into: stratum corneum, hyaline layer, granular layer, spiny layer and basal layer. The dermis is divided into superficial layer and deep layer. Melanocytes are located in the basal layer of the epidermis of the skin. Melanocytes produce melanin, which gives the skin its natural color. When the skin is exposed to sunlight, melanocytes produce more pigment to darken the skin tone, which is a protective response of the body to sun damage. Melanoma originates from melanocytes and is formed when melanocytes become malignant.
When melanoma occurs in the skin, it is called cutaneous melanoma. Those originating from the eyes, nasal cavity, digestive tract, lymph nodes, vulva, and meninges are called mucosal melanomas.
Melanoma can occur at all ages and in any part of the skin. In Caucasians, melanoma commonly occurs on the back, chest, abdomen and lower extremities, while in people of color (including Chinese), melanoma occurs on the extremities, i.e., soles of the feet, toes, ends of fingers and under the nails.
Melanoma usually first involves the adjacent lymph nodes and then metastasizes with the lymph nodes to other parts of the body, such as liver, lung, brain and other organs. The cancer cells in these new tumor foci are still melanoma cells and are called metastatic melanoma.
The survival of melanoma patients is obviously related to the stage, thickness of the primary foci and genetic variation. The more advanced the staging, the thicker the thickness of the primary foci, and the lower the 5-year survival rate. If there are KIT gene and BRAF gene mutations, it suggests a worse prognosis.
2. Is melanoma very common?
Compared with other common tumors, the incidence of melanoma is not high, but melanoma has become the fastest growing malignancy among all malignant tumors in recent years, with an annual growth rate of about 3-5%, with 199627 new cases of melanoma and 46372 deaths worldwide in 2010. According to statistics, the incidence rate of melanoma in developed regions was 9.5/100,000 and 8.6/100,000 for men and women, respectively, and the mortality rate was 1.8/100,000 and 1.1/10, respectively, in 2008. Arizona in Australia and Southern Arizona in the United States are high incidence areas for melanoma, with incidence rates of 44/100,000 and 26/100,000, respectively, and about 10-20/100,000 in Europe. Asian countries such as China and Japan are relatively low compared with European and American countries, but the incidence rate is growing rapidly. According to domestic statistics, the incidence rate of moles in Beijing was 0.3/100,000 and 0.2/100,000 for men and women respectively in 1998, and it has increased to 0.8/100,000 and 0.5/100,000 in 2004; the incidence rate of moles in Shanghai was 0.2/100,000 and 0.3/100,000 for men and women respectively in 1995, and it was 0.5/100,000 and 0.4/100,000 respectively in 2005.
3.Do all moles become melanoma?
The common grayish-black swellings on the skin are: “wart” and “mole”. A “wart” is called a wart in medical terminology and is often caused by a viral infection. A “nevus” is what we often call a mole. A mole is composed of clusters of melanocytes and their surrounding tissue, and can be pink, brown, yellowish-brown, or close to normal skin color. Moles are round or oval in shape and have a flat or raised appearance on the skin surface, usually less than 5 mm. moles can be congenital or formed later in life. Moles rarely regrow in situ after being removed. Most common moles do not develop into melanoma.
In Chinese, melanoma tends to occur at the ends of the extremities, so moles in these areas should be observed more closely. When the size, shape, color and texture of an existing mole change, it needs to be taken seriously. Some melanomas can also develop from newborn moles with uneven color and irregular shape.
4.What will be the manifestation of pigmented mole malignant change?
Malignant change should be alerted when the original mole increases rapidly, becomes lumpy, has blurred edges or satellite nodules, has uneven color, oozes or bleeds, and does not heal after breaking down.
The following is the ABCDE method suggested by experts to determine the early malignancy of moles: A (Asymmetry) asymmetry. B (Border) Irregularity of the edge. The edges are uneven, uneven, and irregularly demarcated from the surrounding area, and there is often pigmentation in the surrounding skin. The color is uneven and can be black, brown, or yellowish-brown interspersed with other colors, such as white, gray, red, pink, or orchid. The diameter is often greater than 5 mm. e (Evolution, elevation, enlargement) Evolution, elevation, and/or enlargement. In some early melanomas, there is a slight augmentation of the entire tumor. The rate of evolution of the tumor is also included. Most early melanomas have the typical ABCDE features, but they can also have only one or two features. Early melanoma can also manifest as neoplastic moles or pigmented spots.
5.Can I go for laser or freezing if I have moles on my body?
Local stimulation such as laser, freezing, knife cutting and rope strangulation may induce malignant transformation and rapid growth of pigmented nevus. If a patient is suspected of melanoma, a complete excisional biopsy is required.
6.Is it possible for the scar after trauma to develop into melanoma?
Not all traumatic injuries can cause melanoma. Experts have confirmed that acute injury does not increase the risk of melanoma formation, but chronic or repeated irritation and injury can increase the risk of melanoma formation. A retrospective study showed a correlation between trauma and extremity melanoma, especially lower extremity melanoma, in a Chinese population. The majority of patients with melanoma of the extremities, especially those located in the feet, had suffered trauma. However, this does not mean that trauma at the extremity site will necessarily lead to melanoma formation, and the role of trauma in the tumor formation process should not be overstated. However, it should be alerted when the scar appears to be broken and enlarged after trauma.
7.Does long-term friction cause malignant transformation of pigmented nevi?
Current research has found that friction does not cause malignant transformation of pigmented nevi. However, the primary lesions of melanoma patients in China are mostly located in the heel, palm, toes and under the nail, etc. The reasons are not clear. Therefore, if the mole performance is prone to breakage after friction, you should seek medical consultation as soon as possible.
8.Is it possible for melanoma to grow on other parts of the body besides the skin?
The most common site of melanoma is the skin, but it can also develop outside the skin such as mucous membranes. The most common skin melanoma is limbal melanoma, which accounts for 41.8% of all melanomas, followed by mucosal melanoma, such as those in the rectum, anus, vulva, eyes, mouth and nasopharynx, which accounts for 22.6% of all melanomas, according to our statistics. The data from our country shows that 22.6% of all melanomas.
9.Who is prone to melanoma?
Studies have shown that people with certain risk factors are more likely to develop melanoma. A risk factor is any factor that increases the likelihood of a person developing the disease. People with the following characteristics are more likely to develop melanoma.
(1) Multiple moles (more than 50) The more moles there are, the more likely they are to develop melanoma. Ancient books have recorded that Liu Bei had more than 70 moles on his body, which is different from normal people. According to the current view, Liu Bei is actually a high-risk group for developing melanoma.
(2) Fair complexion Generally fair-skinned people are more prone to melanoma than dark-skinned people. The former are prone to sunburn or long spots, and the probability of melanoma in white people is much higher than in black people, which may be related to the fact that light skin is more prone to sunburn.
(3) History of melanoma or skin cancer People who have had melanoma are prone to have it again, and in some cases, more than two melanomas can occur. People who have had one or more common skin tumors (basal cell carcinoma or squamous carcinoma) are also at significantly increased risk of developing melanoma.
(4) Family history of melanoma Melanoma can run in families, and if two or more relatives have the disease, the likelihood of developing melanoma is greatly increased. About 10% of people with melanoma have a relative with the disease. When a family member has melanoma, other family members should go to the hospital for regular checkups.
(5) Low immunity People with low immunity are susceptible to melanoma, such as those with tumors, post-organ transplantation, or AIDS.
(6) History of severe sunburn The likelihood of developing melanoma increases if the skin was severely sunburned or even blistered by the sun during early childhood. Therefore, parents are advised to protect their children from sun exposure. Sunburn in adulthood also increases the risk of melanoma.
(7) UV exposure Experts believe that the global rise in melanoma incidence is associated with a significant increase in people’s exposure to sunlight. For example, in the United States, there are more melanoma patients in Tennessee than in Minnesota because UV rays are more intense there. Solar UV exposure causes premature skin aging and damage, which in turn may cause melanoma. Artificial UV rays from sunlamps and tanneries can also cause skin damage and increase the risk of melanoma. That’s why doctors recommend that people reduce their exposure to UV rays, whether natural or artificial.
(8) Inappropriate treatment Inappropriate treatment of moles can significantly increase the risk of developing the disease, such as laser, electric baking, freezing, salting, cutting, partial excision, needle picking, piercing, and string strangulation. The development of melanoma in our patients is mostly associated with this. Inappropriate treatment can stimulate melanoma cells to become malignant or allow melanoma cells in the superficial layer of the skin to infiltrate into the deeper layers of the skin and enter the lymphatic vessels and blood vessels in the deeper layers of the skin, resulting in lymph node metastasis or distant metastasis. Once you suspect that a mole may become malignant, you must go to a specialized hospital first before dealing with it, and never treat it blindly.
10.How to prevent melanoma?
The prevention of melanoma starts with self-examination of the skin and paying more attention to the moles and their changes, especially for the high-risk groups mentioned above. It is important to know the location as well as the appearance of your birthmarks, moles and spots. The examination should include: whether there are new moles, whether there are changes in the size, shape, color and texture of the original moles, and whether there is any breakage on the surface.
Secondly, pay attention to sun protection. The occurrence of melanoma in Caucasians is clearly associated with long-term or intermittent UV exposure. Although the cause of the disease in people of color is still unclear, it is still important to pay attention to sun protection for areas that are frequently exposed to the sun. Ultraviolet light from sunlight burns the skin and induces DNA mutations. Both UVA and UVB can induce melanoma, but UVB is the main cause of damage to certain genes in melanoma cells and induces the development of melanoma. UVA can also suppress certain functions of the immune system, thus accelerating the development of melanoma.
Specific sun protection measures are as follows: (1) Try to avoid going out at noon when the sun is strongest, because the penetrating power of UVB is strong, wear long-sleeved clothes, long pants, a hat with a wide brim and sunglasses that can absorb UVB when going out. (2) Protect your skin with water, creams and gels that contain sunscreen ingredients. The sun protection strength of sunscreens is related to the sun protection factor (SPF), the larger the SPF value, the stronger the sun protection ability. However, sunscreen can only prevent melanoma and other skin tumors to a certain extent, but it cannot replace sun protection measures, nor can it be used as an excuse to extend the sun exposure time. (3) Sun protection should start with children. Since children’s skin is more fragile, too much time playing in the sun may be associated with the occurrence of melanoma in adulthood.
11.What departments should I visit for abnormal moles on my body?
If an abnormal mole is found on the body, you may choose to first visit a dermatologist. After a complete and enlarged excision, if the pathology confirms melanoma, the next treatment requires a team of specialists, including dermatologists, surgeons, medical oncologists, radiologists and plastic surgeons. Patients with such disorders are recommended to go to a hospital with a melanoma specialty.
12.Why should melanoma be treated at an early stage and is it okay if it is “painless”?
If melanoma is diagnosed and treated early, most stage I and II melanomas can be cured by surgery alone. For patients with limited stage without regional lymph node metastasis, the 5-year survival rate is about 85% for stage T1a patients (lesion infiltration depth <1mm), 70% for stage T2a patients (lesion infiltration depth >1mm and <2mm), 55% for stage T3a patients (lesion infiltration depth >2mm and <4mm), and 55% for stage T4a patients (lesion infiltration depth >4mm). The 5-year survival rate was 45% for stage T4a patients (lesion infiltration depth greater than 4 mm) and 15% for stage T4a patients (lesion infiltration depth greater than 4 mm), respectively, if the patients had ulceration of the primary lesion, which was a manifestation of further lesion development. Overall, the 5-year survival rate is 85% for stage I patients, 55% for stage II, about 35% for stage III (presence of regional lymph node metastases), and less than 5% for stage IV (distant metastases).
There are often people who think that “nevus” is broken, but it does not hurt and does not need to go to the hospital. Other people think that “it is best to leave the nevus untouched” and that “it is easy to deteriorate and metastasize if it is moved”. The sooner you operate, the sooner you can get treatment, which is also to save your life. The “nevus” on the foot of Li Xiangshan in “Do Not Disturb 2” was delayed to become a metastasis and lost his life.
13.What tests should be done to confirm the diagnosis after suspected melanoma?
In the case of suspected melanoma, a biopsy is the only means of confirming the diagnosis. During biopsy, the doctor will remove as much of the suspicious tissue as possible, i.e. complete excisional biopsy. If the mass is too large to be removed in its entirety, a partial tissue sample will be taken for examination. If a melanoma is suspected, the doctor will never cut or cauterize it at will. The biopsy is usually performed in an outpatient operating room under local anesthesia, and the excised tissue is sent to the pathology department, where it is embedded, sectioned, and stained with HE to make pathological sections. The pathologist then looks at the sections under a microscope to make a final diagnosis, a process that takes about 1 week, and in some cases, immunohistochemistry is required to confirm the diagnosis. Histopathology is the most important means to confirm the diagnosis of melanoma, together with immunohistochemical staining is more helpful for the differential diagnosis of basal cell carcinoma. Early melanoma must be completely excised from the suspected lesions to obtain accurate T-stage, and local biopsy or needle aspiration biopsy should be avoided as much as possible, except for tumors in special areas such as the face, where whole-layer chisel biopsy can be considered. If the tumor is huge and ruptured, or metastasis has clearly occurred, puncture or excisional biopsy of the lesion can be performed. For sites with very high diagnostic certainty and conditions for sentinel lymph node biopsy, sentinel lymph node biopsy can be performed at the same time as complete resection, or in separate sessions.
14.What other tests should be done after the diagnosis of melanoma is confirmed?
Since melanoma is highly malignant and prone to distant metastasis, a comprehensive evaluation and examination of organs prone to metastasis should be performed after the diagnosis of melanoma is clear. (2) to preserve the basic data at the initial diagnosis to facilitate the evaluation of the efficacy of the treatment plan after treatment. The focus of examination for melanoma varies slightly from site to site, but generally includes ultrasound of superficial lymph nodes, enhanced CT of the head and chest, and enhanced CT or ultrasound of the abdominopelvic cavity. Melanoma of the nasopharynx is best treated with an MRI of the nasopharynx, melanoma of the vulva may require colposcopy, and melanoma of the gastrointestinal tract may require gastroscopy, colorectal microscopy or barium meal of the gastrointestinal tract, etc. The newly emerged PET/CT examination in recent years can not only observe the occupying lesions, but also determine their benignity and malignancy by the ability of the occupying lesions to take up FDG, especially for patients with unknown primary foci, with the disadvantage that it is more expensive.
In addition, routine blood tests, liver and kidney functions, blood glucose and lipids, coagulation tests, electrocardiogram or cardiac ultrasound, and infections such as viral hepatitis, HIV, and syphilis are required. These items are done to understand the general physical condition of the patient to help decide on the next step of treatment. Therefore, there are many more tests waiting for melanoma patients after patiently obtaining the pathological diagnosis and before the initial treatment, but they are an important element and process for the correct diagnosis, directly related to the safety and smoothness of the subsequent treatment, and a necessary prerequisite for the correct choice of treatment plan.
15.Are all melanomas fatal? How is it staged?
Melanoma is a tumor with extremely high malignancy and aggressiveness. There is a lack of effective treatment for advanced melanoma, and patients have a short survival period. According to statistics, the median survival in the period of distant skin lymph node metastasis is 13 months, lung metastasis only is 8 months, liver and brain metastasis is 4 months, and bone metastasis is 6 months. However, early melanoma can be completely cured through standard treatment.
16.How is melanoma staged?
So how to stage melanoma? Currently, TNM staging of melanoma is usually performed internationally with reference to AJCC staging standards. T staging depends on the thickness of the primary lesion, N on the number of lymph node metastases, and M on the presence of distant metastases that are different from the primary lesion. The disease is then classified into stages I-IV according to the results of TNM staging. Generally speaking, as long as there are distant metastatic lesions, the disease is classified as stage IV.
17.How to choose the treatment plan after the diagnosis of melanoma?
The choice of treatment plan for melanoma depends on the severity of the disease, the patient’s age, general health status and other factors.
Early stage patients undergo surgical resection as the fundamental treatment (complete and expanded resection). The safe margin for an extended resection is determined by the depth of tumor infiltration in the pathology report. Amputation is not advocated, and current evidence-based medical evidence still supports that a margin of 50px is sufficient. Patients with definite regional lymph node metastases require lymph node dissection, which requires complete removal of the base of the involved lymph nodes rather than individual lymph nodes.
Except for very early stage patients, most patients with cutaneous melanoma require further systemic therapy after surgery to reduce the risk of recurrence; the current international and domestic recommended treatment is high-dose a-2b interferon therapy, which is a biological agent injected subcutaneously and, unlike chemotherapy, mainly kills tumor cells by regulating the body’s immune system, in addition to directly killing tumors and inhibiting tumor angiogenesis. Adjuvant therapy for mucosal melanoma (including GI tract, genital tract, nasal cavity and eye) is inconclusive, and it is generally believed that chemotherapy is more effective than interferon.
The survival period for advanced melanoma is short. There is a lack of effective treatment, and a combination of chemotherapy, targeted therapy and immunotherapy is generally recommended, and participation in clinical trials is recommended. Patients with brain metastases or bone metastases also need to use local radiotherapy, and patients with bone metastases need to be treated with bisphosphonates to inhibit osteoclasts from producing further osteolytic destruction and reduce events such as pathological fractures. Combined hepatic artery interventional embolization chemotherapy is generally recommended for patients with melanoma liver metastases.
18.Is amputation necessary after the diagnosis of melanoma?
Melanoma is commonly known as the “king of cancers”. In the past, many patients and doctors were afraid of this disease, and once melanoma occurred in the limb, they hoped that the surgery would be as big as possible, as if it could prevent future recurrence and metastasis. In fact, amputation does not reduce the risk of recurrence and metastasis, and many studies have found that the risk of recurrence and metastasis is not reduced beyond a certain margin. How can we determine the most appropriate extent of resection? A large number of studies have found that the safe margin of enlarged resection should be determined by the depth of tumor infiltration in the pathology report: 25px when the lesion thickness is ≤1.0mm, 1-50px when the thickness is 1.01-2mm, and 50px when the thickness is >2mm. When the thickness is >4mm, some scholars believe that the safe margin should be 75px, but The current evidence-based medical evidence still supports that a safe margin of 50px is sufficient. Unless there are some special circumstances, such as oversized lesions or special anatomical locations, the limb should be preserved as much as possible.
19.What is an anterior lymph node biopsy and in what kind of cases is it necessary?
The sentinel lymph node of malignant melanoma is a special type of lymph node among the lymph nodes in the drainage area of the primary tumor, which is the first lymph node through which it metastasizes and is considered as the body’s own barrier to stop the lymphatic metastasis of the tumor. Sentinel lymph node biopsy (SLNB) is a minimally invasive procedure. It is performed by injecting a specific drug around the lesion to locate and biopsy potentially metastatic lymph nodes, thereby clarifying the presence of metastasis in the sentinel lymph node. For patients with stage IB to stage II (large depth of tumor infiltration), the panel recommends the use of sentinel lymph node biopsy to guide the next step of antitumor treatment and intensity.
20.After surgical treatment, do I need further drug treatment?
Except for a small number of very early stage malignant melanoma, patients who have achieved R0 resection (i.e. complete removal of the tumor at the site of disease and no tumor foci in the body) are recommended to undergo post-surgical adjuvant antitumor therapy.
For malignant melanoma of skin origin, post-operative adjuvant drug therapy is recommended with high-dose a-2b interferon therapy, which should be maintained for about 1 year, and interferon is a biological agent injected subcutaneously and can also be injected intravenously. Compared with chemotherapy, its adverse effects are less severe. The adjuvant treatment for mucosal melanoma (including gastrointestinal tract, genital tract, nasal cavity and eye) is still inconclusive, and it is generally believed that chemotherapy is more effective than interferon.
21.How should I choose the treatment plan once melanoma metastasis occurs?
Once melanoma metastasis occurs, a combination of chemotherapy-based treatment should be considered. Among the chemotherapy drugs, the first-line treatment is recommended as Dacarbazine (DTIC) monotherapy, Temozolomide (TMZ) or TMZ/DTIC monotherapy-based combination therapy (such as combined with cisplatin or Formostane), with low efficiency, generally considered to be about 15-20%; the second-line treatment is generally recommended as paclitaxel combined with carboplatin, with an efficiency of about 20 The second-line treatment is generally recommended for paclitaxel combined with carboplatin, with an effective rate of about 20%.
In recent years, with the development of biotechnology, new targeted immunotherapeutic drugs have been introduced and have achieved impressive results, such as Ipilimumab and Vemurafenib. However, these drugs also have their limitations, such as high price, low overall response rate, short maintenance time after drug onset, and need to be targeted to selective patients, not suitable for all populations.
Patients with brain metastases or bone metastases also need to be treated with local radiotherapy, and patients with bone metastases need to be treated with bisphosphonates to inhibit osteoclasts from producing further osteolytic destruction and to reduce events such as pathological fractures. For patients with melanoma liver metastases, combined with hepatic artery interventional embolization chemotherapy is generally recommended, and the commonly used drug is cisplatin. Interventional embolization chemotherapy enables chemotherapy drugs to better contact with tumor lesions in the liver to improve treatment efficiency, which can effectively increase about 10 times compared with systemic intravenous chemotherapy.
Limb metastasis is a specific type of metastasis in limb melanoma, which refers to metastatic lesions in the skin or subcutaneous soft tissue that occur between the primary lesion 50px away and the regional lymph nodes via lymphatic vessels. This type of metastasis is poorly treated with conventional intravenous chemotherapy. Isolated limb infusion chemotherapy (ILI) has a control rate of 50-80% for metastases to the migrating limb and is widely used internationally. The principle is to puncture the indwelling catheter from the femoral static artery in the opposite inguinal region of the affected limb respectively, deliver the catheter to the level of the knee joint of the affected limb, and then briefly block the patient’s blood flow with a tourniquet at the root of the affected limb under general anesthesia while the affected limb is heated to about 41 degrees, and infuse the muffler from the catheter for 30 minutes of repeated circulation, and finally flush the muffler with crystalloid, and finally remove the tourniquet to restore blood flow. The advantage of this treatment is that the lesion can be better controlled while preserving the limb.
22.Is melanoma contagious or hereditary?
Melanoma is not contagious. The onset of melanoma is closely related to the immune system. In normal people, a few cells are malignant every moment, but the immune system can quickly detect and destroy them, so they do not suffer from tumors, while the immune system in melanoma patients is either unable to recognize the bad cells in disguise or does not have enough ability to kill the bad cells, and therefore suffer from the disease. Therefore, even if a normal person comes in contact with secretions from a melanoma patient’s lesion, the body’s immune system can respond quickly to destroy them.
However, if a relative has melanoma, the risk of developing melanoma is about 8-9 times higher, and if a relative has skin cancer, the risk of developing melanoma is about 2-3 times higher. In foreign studies, melanoma clustering has been found in some families, but no such cases have been found in China. Regular skin self-examination can lead to early detection and treatment, and sun protection can also prevent melanoma. Protecting the environment, maintaining good habits, exercising properly, and improving the immune function of the body have the potential to reduce not only the chance of melanoma, but also the common principle of reducing the incidence of other malignant tumors.