MELANOMA

From Big Medical Encyclopedia

MELANOMA (melanoma; grech, melas, melanos black, dark + - oma; synonym: melanoblastoma, melanocarcinoma, melanosarcoma, melanotsitoma, nevocarcinoma) — the malignant tumor developing from pigmentobrazuyushchy cells. It is for the first time described in 1864 by Virkhov. M.'s etiology is not found out.

Primary center of M. can be located on various sites of skin, less often on a mucous membrane went. - kish. a path and upper respiratory tracts, in an eyeglobe, a meninx.

The melanoma of skin

the Melanoma of skin meets more often M. of other localization. According to most of authors, more than in 90% of cases the tumor is found on skin of the lower extremities, trunks and persons. At the same time at M. women is located on skin of the lower extremities more often, men have trunks. The m meets on the open body parts subject to action of sunshine more often. At representatives of races with fiziol, is located with the expressed xanthopathy of M., as a rule, on rather poorly pigmented sites (a palm, foot, a conjunctiva, a mucous membrane of an oral cavity, etc.). In various countries M.'s incidence fluctuates over a wide range, napr, in Japan and India among locals M.'s incidence, according to McGovern et al. (1970), makes 0,2 — 0,3, in Australia — 16,4 on 100 000 population. A number of the factors influencing M.'s emergence skin is allocated: the raised solar radiation, sunblisters, an injury of a nevus and some other. According to many scientists, M. develops against the background of melanosis (see), in 50 — 70% of cases — against the background of nevus (see), especially at persons with the lowered xanthopathy. The malignancy of a nevus can come both at repeated, and at its single traumatization.

The pathological anatomy

Macroscopically primary center of M. of skin can have an appearance of papilloma, ulcer or formation of the irregular, rounded, oval shape with various extent of pigmentation. In some cases at so-called amelanotichesky (pigment-free) M. pigmentation of primary center of M. is absent. The m of type malignant lentigo usually has an appearance of the center of brown color with uneven contours, reminding freckles (see). The nodal form M., as a rule, has an appearance of the education acting over the surface of skin, or a bluish-black plaque with uneven contours.

Fig. 1 — 4. Microdrugs of a melanoma of skin of various cellular structure: the field of vision is covered with preferential epithelial-like (fig. 1), spindle-shaped (fig. 2), nevusopodobny (fig. 3) and ballonoobrazny (fig. 4) cells. Fig. 5. Microdrug of skin at a melanoma in the third stage of infiltrative growth: under epidermis (1) the cells (2) tumor cells filling a papillary layer of a derma are visible; in a mesh layer of a derma dense infiltration (3) lymphoid plasmocytes and macrophages. Fig. 6. Microdrug of skin at a melanoma in the fourth stage of infiltrative growth: cells (1) of tumor cells are located in a papillary and mesh layer of a derma; focal infiltration (2) dermas lymphoid and plasmocytes is visible.

The cellular structure of M. is various. Distinguish four types of the melanocytes (tsvetn. fig. 1 — 4) which are preferential found in a tumor: 1. Epithelial-like cells with roundish often hyperchromic kernels and the plentiful light cytoplasm which is quite often containing yellow-brown inclusions of a pigment melanin (see). The arrangement of chromatin in the form of threads in kernels of separate epithelial-like cells creates a picture of peculiar radiant figures. 2. The spindle-shaped cells of the extended form which are usually forming randomly intertwining bunches are more rare concentric figures. 3. Nevusopodobny cells — small, a rounded or oval shape of a cell with hyperchromic kernels. 4. Ballonoobrazny cells with rather small hyperchromic kernels surrounded with a wide zone of optically void cytoplasm. In M. can meet also huge one - or multinucleate cells.

At gistol, a research find signs of infiltrative growth of a tumor, in Krom, according to Clark (W. N of Glare), etc. (1969), allocate five stages: The I stage — a tumor is located in epidermis; The II stage — tumor cells get through a basal membrane of epidermis into a papillary layer of a derma; The III stage — tumor cells fill a papillary layer of a derma, reach a mesh layer, but do not get into it (tsvetn. fig. 5); The IV stage — an invasion of tumor cells in a mesh layer of a derma (tsvetn. fig. 6); The V stage — tumor cells are located in hypodermic cellulose. More exact data on extent of infiltrative growth of M. can be obtained during the use of the technique of Breslou (1970) based on measurement at gistol. research of thickness of primary center of a tumor.

Besides, depending on the preferential direction of growth of a tumor within skin distinguish phases of radial and vertical growth of M. V to a phase of vertical growth the tumor passes the specified stages of infiltrative growth.

Proceeding from morphological, and also a row a wedge. features, allocate three main types of a tumor: on verkhnostno-extending, like a malignant lentigo and nodal.

Development by the superficial extending M. takes place originally a phase of radial growth, in a cut growth of tumor cells towards a corneous layer of epidermis and radially within epithelial layer is noted. Microscopically at the same time epidermis is thickened by 2 — 4 times, is characterized by various degree of a hyperkeratosis, is partially replaced with big atypical melanocytes with light cytoplasm and hyperchromic kernels. In an acanthceous layer of epidermis the melanocytes reminding Pedzhet's cells can meet. Separate tumor cells usually contain the sprayed inclusions of a pigment in cytoplasm. In a phase of radial growth usually find the expressed infiltration of a derma lymphoid, plasmocytes and macrophages. In a phase of vertical growth by the superficial extending M. it is observed deep penetration of tumor cells into a reticular layer of a derma and hypodermic cellulose. In this phase tumor cells usually have a little smaller sizes, hl. obr. due to reduction of volume of cytoplasm. At the same time in some cases there can be a moderate infiltration of a derma lymphoid and plasmocytes.

At M. of type malignant lentigo in a phase of radial growth in a basal layer of epidermis proliferation of melanocytes is noted. Invasion of tumor cells of hl. obr. a spindle-shaped form in a papillary layer of a derma it is quite often combined with proliferation of melanocytes of an external part of hair follicles and sometimes sweat glands. In a derma infiltration can be observed by lymphoid cells, histiocytes and macrophages.

Development of a nodal form M. is characterized only by a phase of vertical growth, at a cut there is an invasion in a papillary, mesh layer of a derma and hypodermic cellulose. Cellular reaction in a derma at the same time, as a rule, is absent.

The m metastasizes in the lymphogenous and hematogenous way, dissimination on skin with existence of local and quite often remote metastasises in skin and hypodermic cellulose is characteristic. At hematogenous innidiation lungs and a liver are surprised more often, in an end-stage of M. metastasises can be found in any body.

The histogenesis, according to most of authors, is connected with the melanocytes having a neurogenic origin and possessing a peculiar secretory function, as a result cover melanin gets into epithelial cells.

Clinical picture

is visible to Fig. 7. Melanoma of skin: on border of a medial and bottom part of foot the knotty bleeding tumor of an oval form. Fig. 8. Melanoma of skin: the knotty bleeding tumor on skin of a back of the child of 4 years. Fig. 9. Recurrent melanoma of skin: on the medial surface of a forearm multiple nodes of a tumor against the background of keloid cicatrixes after a cryolysis. Fig. 10. Intradermal metastasises of a melanoma. Fig. 11. Macrodrug of a femur (a vertical cut) with nodes of metastasises of a melanoma in spongy and compact substance of a bone. Fig. 12. Melanoma of an eye: in a tsiliarny zone of an iris the knotty tumor is visible

Development of primary center of M. begins usually with increase in the sizes of a pigmental nevus or with emergence of a nevus pigmentosus on not changed skin. Discoloration of a nevus, its ulceration or bleeding at easy traumatization can sometimes be the first manifestations of M. (tsvetn. fig. 7 — 8). In rare instances of primary and metastatic M. of skin the nevus externally does not change, and the first a wedge, metastasises of a tumor are symptoms. Metastasises in limf, nodes and emergence of so-called satellites around a nevus pigmentosus or at the basis of pigmental papilloma are signs of lymphogenous innidiation of M., the center a cut is located, apparently, in the pigmental education which is not changed by sight. Primary center of M. can also be unnoticed when it has the microscopic sizes or does not contain inclusions of a pigment. In some cases such a wedge, a picture it is caused by so-called spontaneous regression of primary center of M., as a result cover sites of a tumor change the color on blue, grayish and white; further the tumor can disappear and on its place there is a depigmented site of skin.

In process of growth of primary tumor around it there are radial beams, affiliated pigmental inclusions in skin — satellites (tsvetn. fig. 9), intradermal (tsvetn. fig. 10), hypodermic and remote metastasises. Regional metastasises are defined in the form of dense limf, nodes, at further development to-rykh conglomerates with involvement of surrounding fabrics and skin are formed. In late stages of process it can be observed melanuria (see).

Features the wedge, pigment-free M.'s currents is extensive defeat regional limf, nodes, at the same time there are metastasises in a bone rather more often (tsvetn. fig. 11).

The diagnosis

For M.'s diagnosis is used tsitol, and gistol, methods of a research, apply test with radionuclide 32 P. At reception of radionuclide 32 P its accumulation in a tumor can exceed several times control indicators in symmetric sites of normal skin. Degree and rates of distribution of tumoral process allow to specify studying of excretion phenolic to - t, increase in contents to-rykh in urine is characteristic in the period of emergence of metastasises. Methods rentgenol, and a radio isotope research use for diagnosis of the remote metastasises of M. The differential diagnosis is carried out with angioma (see), cancer (see), sarcoma (see), histiocytoma (see), xanthoma (see), Bowen's dermatosis (see. Bowen disease ). At children the differential diagnosis is carried out with a so-called juvenile melanoma, edges it is observed during before puberty and is special type of a nevus.

Treatment

in the presence of primary center without metastasises apply operational treatment with broad excision of primary center. When at it gistol, a research the III—V stages of infiltrative growth of a tumor come to light, in addition appoint antineoplastic means — a nitrozometilmochevina, Vincristinum and Dactinomycinum. In the presence of M.'s metastasises, besides, carry out a regional limfadenektomiya and treatment to regional limf, nodes by antineoplastic means in combination with immunotherapy (see). When operational treatment is not feasible, apply treatment by antineoplastic means in combination with radiation therapy (see), napr, carry out radiation against the background of purpose of Dactinomycinum. At treatment of the disseminated forms M. with existence of intradermal metastasises and a recurrence operational or cryosurgical treatment is combined with purpose of antineoplastic means, carrying out an immunotherapy, radiation therapy, and also regional chemotherapy by means of infusion or perfusion of antineoplastic means. At hematogenous dissimination of M. apply hl. obr. all-resorptive chemotherapy, hormonal drugs appoint and carry out an immunotherapy.

The forecast

the Forecast depends on features a wedge, currents and gistol, stages M. Tak, in the presence of primary center in the I—II gistol, propagation steps in most cases operational treatment leads to full treatment, at the III—V gistol, stages of infiltrative growth the forecast is less favorable and. according to a number of authors, life expectancy of patients within 5 years after operation is observed in 45 — 70% of cases; when there are metastasises in regional limf, nodes, such life expectancy is observed less than in 30% of cases. In the presence of the remote metastasises of M. (is more often in skin and soft tissues) the favorable forecast is observed only in isolated cases.

Prevention

Prevention — removal of a nevus in the operational way at persons with the lowered xanthopathy, and also excision of pigmental educations at detection of change of their sizes, colors, emergence of ulcerations and bleeding at easy traumatization.

The melanoma of a soft cover of a head and spinal cord

the Melanoma of a soft cover of a head and spinal cord meets extremely seldom. Macroscopically meninx (see) are sharply thickened (to 1 cm), dark brown or black color. The wedge, a picture is characterized by pristupoobrazny headaches, nausea, vomiting, a stiff neck, existence of developments of stagnation on an eyeground, etc. The diagnosis is established at gistol, a research of a remote tumor.

Treatment operational with the subsequent purpose of antineoplastic means — nitrozometilmochevina, Vincristinum and Dactinomycinum. Forecast, as a rule, adverse.

The melanoma of an eye

the Melanoma of an eye can come from the vascular highway of an eyeglobe, a conjunctiva, an episclera, and also from the subsidiary bodies of an eye.

The m of a vascular path of an eyeglobe is observed more often at the age of 50 — 60 years, can result from a malignancy of a nevus or against the background of an inborn melanosis of an eye. Depending on localization of primary node of a tumor distinguish M. of an idiovascular cover (horioidea), a ciliary body and an iris.

The pathological anatomy

Macroscopically the most frequent form of a tumor is nodal, plane meets less often. Nodal M. of an idiovascular cover stretches a vitreous membrane, quite often destroys it and freely expands in subretinal space, forming a node of a fungoid form. At a plane form M. of an idiovascular cover the vitreous membrane usually is not damaged and is not exposed to noticeable stretching. In the course of M.'s growth can get into emissarny veins and go beyond an eyeglobe. Development of an episkleralny node of a tumor leads to infiltration of cellulose of an eye-socket with restriction of mobility of an eyeglobe and development exophthalmos (see). On a microscopic structure usually allocate four types M. of an idiovascular cover: fusocellular, fascicular, epithelioid and mixed.

A clinical picture

On a wedge, allocate to a current four stages of development of M. of an idiovascular cover: I \the initial stage which is characterized by development funkts. frustration; II \stage of development of secondary complications; III \a stage of spread of a tumor out of limits of an eyeglobe; IV \stage of generalization of a tumor.

The most short-term is the initial, I stage of M. of an idiovascular cover, a coming from macular and paramacular zone. The dystrophic changes in a retina arising at the same time over a tumor lead to early funkts, changes in a look photopsias (see), metamorphopsias (see) with disturbance of visual acuity and central scotoma (see). At M.'s localization in peripheral departments of an idiovascular cover funkts, changes develop later. At an oftalmoskopichesky research during this period on an eyeground find the compact node with a clear boundary acting in a vitreous.

In the II stage increase in the sizes of a tumor is followed by the circulator frustration leading to accumulation of exudate in subretinal space and to amotio of a retina (see). In a tumor dystrophic changes, hemorrhages, necroses, reactive inflammatory processes are noted, to-rye can create a wedge, a picture of inertly current uveitis (see), acute iridocyclitis (see) or is more rare entophthalmia (see), to-rye can develop in an initial stage, complicating diagnosis of a disease. Circulator frustration and inflammatory processes create premises for development of secondary glaucomas (see), very characteristic of the II stage of a disease.

In the III stage of a disease episkleralny or subconjunctival growths, an exophthalmos appear.

In the IV stage find M.'s metastasises in internals, is more often in a liver.

The m of a ciliary body in an initial stage causes according to the sector of an arrangement of a tumor crimpiness and a congestive hyperemia in system of front ciliary (tsiliarny) vessels, irregularity of depth of an anterior chamber of an eye, flattening of edge of a pupil, a contact phacoscotasmus in the field of a tumor. The first the wedge, symptoms of a tumor can be its germination in a corner of an anterior chamber — emergence of a crescent strip along a root of an iris or a limited node, as if a coming from root of an iris. Also perhaps early penetration of a tumor into system of front tsiliarny veins with development of an episkleralny node and emergence of a hull behind a limb.

M of an iris (tsvetn. fig. 12) can close a part of a pupil, fill the camera in the sector of growth and get into a ciliary body. Idiosyncrasy of a so-called iridotsiliarny (anulyarny) form M. is circular growth of a tumor along a big arterial circle of an iris with early penetration into the filtrational device and into a corner of an anterior chamber. In this regard there can come blockade of the filtrational device and development of secondary glaucoma as conducting a wedge, a symptom of an initial stage of development of a tumor.

The diagnosis

diagnostic mistakes at plane M. V are Most frequent of an initial stage of M., especially at an amelanotichesky form, there can be inflammatory reactive processes with involvement of a retina over a tumor and the subject sclera, to-rye quite often treat and treat as recurrent uveites, chorioretinites and sclerites. Therefore at amotio of a retina, the unilateral progressing glaucoma, at sudden rapid development in an eye of inflammatory changes, spontaneously arising hemorrhages, and also at recurrent iridocyclites, chorioretinites careful differential diagnosis for an exception of M shall be carried out. For this purpose, in addition to usual methods of a research and overseeing by dynamics of development of a disease, apply ultrasonic and radio isotope researches, fluorescent angiography (see), etc.

Treatment

In most cases M. of own choroid and a ciliary body carry out fluorescence analysis enucleation of an eye (see). Also apply operations of local removal of tumors within healthy fabrics in the way corectomies (see), iridotsiklektomiya (see), iridotsiklosklerektomiya and horioidektomiya by means of the microsurgical equipment (see. Microsurgery, in ophthalmology ). According to indications carry out laser and M.'s photocoagulation of an eye, methods of a cryosurgery apply (see. the Cryosurgery, in ophthalmology ). In some cases operational treatment is combined with radiation therapy, to-ruyu appointed at detection of ekstrabulbarny growths in the postoperative period. At massive tumoral infiltration of cellulose of an eye-socket carry out ekzenteration of an eye-socket (see) with the subsequent chemotherapy.

Forecast depends on M.'s localization eyes, a wedge. stages, gistol, structures, mitotic activity of tumor cells and existence of secondary changes. More favorable forecast at a fusocellular gistol. type M. and the least favorable — at epithelioid and mixed gistol, types.

The melanoma of digestive tract

the Melanoma of digestive tract meets seldom, preferential in thin and a rectum. The main a wedge, manifestations are impassability of intestines, bleeding and an itch at an arrangement of primary center of M. in the field of an anus. The m went. - kish. a path it is characterized by rapid growth with perforation of a wall of a gut, development of a peritoneal melanomatosis and peritonitis.

Treatment operational. Methods of cryosurgical and himioimmunoterapevtichesky treatment are developed.

Forecast, as a rule, adverse.



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S. M. Parshikova, V. V. Yavorsky; A. A. Horasyan-Tade (oft.).

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