Melanoma in children

Melanoma in children is a malignant skin formation that has very aggressive growth and rapidly metastasizes. This pathology refers to oncological diseases of childhood, whose treatment is difficult. Fortunately, melanoma is very rare in children, so knowing the symptoms and the main manifestations of the disease is very important for timely treatment.

[1], [2], [3], [4],

Epidemiology

Epidemiology of melanoma is not strongly developed, since melanoma among all oncological pathologies of childhood is less than one percent. But since this disease is not so common, then its diagnosis is not always timely. In the age structure of melanoma in children less than ten years is 5% of the total incidence of cancer, and in children over 10 years this figure is 15%. That is, melanoma is more common in pre-pubertal and pubertal children.

[5], [6], [7], [8], [9]

Causes of the melanoma in the child

The reasons that underlie the development of any oncological pathology can not yet be established accurately. Therefore, it is very difficult to talk about the obvious cause of melanoma in children. To find out what factors can influence the formation of melanoma in a child, you need to understand the pathogenesis of this disease.

The skin of the child consists of the epidermis, the skin itself or the dermis and subcutaneous tissue. In the dermis of each person there is melanin - this is the pigment, which is responsible for the color of the skin. If a person has little of this pigment, then his skin is light and slightly inclined to tan, and if there is a lot of melanin in the dermis, a person can be swarthy. Still it is necessary to tell or say about pigmentary nevuses or as in the people speak about rodinki. These are formations on the skin that are benign and consist of a cluster of several melanocyte cells. Under normal conditions, they do not change and do not grow. Melanoma is a skin tumor in which it is these cells that are melanocytes that degenerate and become malignant. And the moment when this degeneration occurs and must be diagnosed in time.

[10]

Risk factors

Given all the reasons, it is possible to identify the risk factors for melanoma development in children, taking into account their young organism and the ability to correct various mutations. The main risk factors are as follows:

1. albino children are more prone to melanoma because their skin is not at all protected from UV radiation;
2. the presence of skin cancer or melanoma in the family, even in remote cases;
3. Mom with harmful factors of labor during pregnancy by the given child (paints, varnishes, chemical shops);
4. severe intrauterine infections or viral lesions may further cause a mutation.

This is by no means all causes of melanoma development, since it is impossible to pinpoint them, but the main ones, and it is necessary to take into account and prevent the complications that are associated with it. 

[11], [12]

Pathogenesis

The pathogenesis of any oncological pathology is that a mutagen acts on the cell. Mutagen is the factor (cause), which acts on the division of cells. Under normal conditions, the cell at a certain time is divided by mitosis, resulting in the formation of two new cells, and the old one dies. If a mutagen acts on the cell, then mitosis is disrupted and uncoated fission occurs in this case of melanocytes, and the old cell does not die. Such uncontrolled growth occurs very quickly, which leads to an increase in the number of melanocytes and they interfere with the growth and reproduction of skin cells. Therefore, an excessive number of such malignant cells leads to disruption of function and rapid germination into the deep layers of the dermis.

Given such a mechanism of melanoma formation, there can be a lot of reasons, that is, mutagens. The most powerful mutagens are viruses that are capable of inducing a change in the cell nucleus and a violation of the normal division process. Also, the cause may be chemical compounds that act on the skin. Given the direct effect on the skin itself, the main cause of melanoma development can be considered ultraviolet irradiation. Since melanin is formed in the melanocytes themselves under the influence of the rays, this kind of irradiation can cause malignant growth of these cells. And it's not about the excess of radiation, but just about its availability. It is very important in the development of melanoma genetic predisposition, because if there are certain genes, even the "lightest" antigen can trigger the reaction of abnormal division.

[13], [14], [15], [16], [17], [18], [19], [20], [21], [22]

Symptoms of the melanoma in the child

The first signs of melanoma are always visible, as this malignant formation of external localization. And this pathology is diagnosed by parents quite widely, as they pay attention to the child during bathing or simply taking care of health. Therefore, if you know exactly what to look for, the symptoms of melanoma can be seen.

At the birth of the child, there are usually no moles. They begin to appear after a while and grow with the child, but to small sizes. In this case, birthmarks should be the same color, more often brown, with even contours, without growths and different inclusions. With such signs it is a normal nevus or birthmark spot. Symptoms of melanoma can be a sudden onset of nevus growth, a change in its color and color, if it is paler in the center, and around it is lighter. There may also be the appearance of redness, itching, pain around the birthmark. If the edges and contours become uneven, pathological inclusions have appeared, or the child scratches the area of the nevus, this is also a symptom of a possible malignant formation. Therefore, it is important for the mother to remember that if the birthmark was the whole life of the child by itself, but suddenly something changed in the characteristic of the given birthmark, then only one sign can be a symptom of melanoma. With any such change, you need to contact the doctor.

Melanoma of the skin in children can manifest in a different way. There are different types of melanoma, including non-pigment, which is not associated with symptoms of a change in the nature of the nevus. Therefore, such melanomas are more difficult to diagnose. In this case, the first clinical sign may be an increase in regional lymph nodes. The lymphoid system of a person, especially a child, is very well developed and tries to limit and remove from the body all unnecessary toxins and substances. So in melanoma, the lymph nodes try to remove all malignant cells, and they accumulate there. So the main and only first symptom may be an increase in such lymph nodes. Then the child can complain of the appearance of densification in the groin or under the arm, soreness.

A pigment-free melanoma in a child does not appear on the skin, but there is only an invasion into the deeper layers of the skin, which can cause an imperceptible compaction. Depending on the immersion of melanoma deep into the dermis, different stages of melanoma are isolated in children, which is important for evaluating the prognosis and choosing the method of treatment.

Stages

The stages of melanoma depend on which layers are involved in the process.

• Stage 1 is when malignant cells of altered melanocytes do not spread beyond the epidermis and the basal membrane does not germinate, this is considered to be the most prognostic stage;
• 2 stage - the process extends to the basement membrane of the epidermis;
• Stage 3 - spread to the papillary layer of the dermis, without reticular invasion;
• Stage 4 - tumor cells spread to the entire dermis layer;
• Stage 5 - the disease is widely invades subcutaneous fat tissue with regional and distant metastases.

This staging can be done only after a thorough histological examination, and in the future it allows to establish the stage of the disease itself and determine the treatment.

The initial stage of melanoma in children is considered the most acceptable for a good result of treatment. This is due to the fact that in this case there are no regional and distant metastases and removal of the primary tumor can lead to complete recovery.

[23], [24], [25]

Complications and consequences

The consequences of untimely diagnosis of melanoma are very serious, because this disease is very prone to metastasis. Therefore, the most frequent complications can be metastases to the liver, which disrupts blood circulation. Therefore, there may be thrombosis of the hepatic vein, necrosis of liver cells. Among the long-term consequences of melanoma and the treatment carried out may be a delay in the growth of the child, a violation of the formation of blood cells. The most serious complications can develop on the background of chemotherapy, which is manifested by anemia, a decrease in the number of leukocytes, infectious diseases, fungal lesions of the mucous membranes.

[26], [27], [28], [29], [30]

Diagnostics of the melanoma in the child

Early diagnosis of melanoma is equivalent to complete recovery, so it is very important, if only my mother saw any changes in the birthmark, you should immediately seek advice from a pediatric dermatologist.

For the correct diagnosis before the examination it is necessary to find out how the nevus behaved during the life of the child and from what point it began to disturb. You just need to ask the child's reaction to sunbathing in the sun and whether there are any changes in the nevus. It is necessary to clarify the family history, whether there is cancer of the skin, melanoma, or any other oncopathology in the family, because there may be a genetic predisposition to mutation of the mitotic cell division gene.

When examining, you need to pay attention not only to what worries your mother at the moment, but the condition of the entire skin of the child. If the child is white and not prone to sunburn, then you should pay attention to it, then the nevi will be clearly visible. Also it is necessary to pay attention to all other pigment spots for the purpose of differential diagnosis.

Analyzes that are performed in melanoma in a child are specific histological studies. Given that melanoma has a high risk of rapid metastasis, a puncture biopsy with suspicion of melanoma is strictly prohibited. Therefore, an excisional biopsy is performed, that is, a skin smear is taken and examined under a microscope. Histological examination makes it possible to establish exactly the diagnosis of melanoma. The benefit of this diagnosis is evidenced by the appearance of cells with atypical nuclei, a violation of the mitosis process, a violation of the very structure of skin tissue. In parallel, various chemical reactions of coloring such cells with different dyes are carried out, which makes it possible to distinguish between skin cancer and melanoma.

Instrumental diagnosis of melanoma is reduced only to conducting a differential diagnosis in complex cases, until the moment when there are no results of a biopsy. You can conduct dermatoscopy - this study of the skin with a special device that increases several dozen times and allows you to see more serious changes in the skin and its appendages. So you can see parasites or fungus, which can cause lichen, which can be similar to, for example, a non-pigmented melanoma.

If the diagnosis of melanoma for a child is established, it is very important to determine the stage of a comprehensive examination - computer tomography. This method allows you to determine the damage of regional lymph nodes and determine the condition of internal organs, where melanoma can be metastasized - for example, the lungs or the liver.

Thus, if there is a histological confirmation, then the diagnosis of melanoma leaves no doubt, and it is important only to determine the stage.

[31], [32], [33], [34], [35], [36]

Differential diagnosis

Differential diagnosis of melanoma in children should be performed with lymphadenopathy of infectious genesis, if the child has enlarged lymph nodes, as a symptom of melanoma. If the lymphadenopathy is infectious, then such nodes are moderately enlarged, symmetrical, can be painful and not soldered to surrounding tissues. Under the influence of antibacterial or other aetiological therapy, such nodes go away very quickly. If the cause is melanoma, then they are enlarged on one side, corresponding to its localization, and huge sizes, not soldered to the tissues.

Bespepigmental melanoma should be carefully differentiated with lichen. Such melanoma can be accompanied by only a slight condensation of the skin, without visible external changes. Lishay is also accompanied by a tightening, an eminence above the skin with a slight rim of redness. In this case, it is necessary to conduct dermatoscopy, and it is possible to see parasites or characteristic signs of deprivation.

In newborns, melanoma is extremely rare, but often there are hemangiomas of small size, to which the mother does not pay attention and does not treat. Then with time, when the child grows, such hemangiomas also grow. They can be brown, fuzzy outlines, which is very similar to melanoma. Therefore, it is also necessary to clearly distinguish these two pathologies, specifying the time of onset of symptoms and conducting additional studies.

Treatment of the melanoma in the child

The peculiarity of melanoma treatment is that this malignant form is very unsuitable for the action of chemotherapeutic agents and radiotherapy. The main approach in the treatment of melanoma in a child is as follows: the initial stages of melanoma (the first and second) are treated surgically, since at this stage the spread of the tumor allows it to be removed within the healthy tissues. The more the stage of the disease, the more methods are used - in the third and fourth stages, a combined and complex method is preferred.

For conservative therapy, medication is used, according to the stage and protocol of treatment. For this purpose, several cytostatics with different mechanisms of action are used at once. Such therapy is very aggressive in relation to healthy tissues and baby cells, considering that it is a growing organism. Therefore, against the background of cytostatic therapy, a lot of drugs are used to protect and maintain the function of the child's internal organs - antiemetic, probiotics, vitamins, parenteral nutrition, antihistamines, antibiotics and antiviral drugs. The main cytotoxic drugs used in the treatment of melanoma in children are Doxorubicin, Vinkristin, Asparginase, Dakarbazin, Prospidin.

1. Doxorubicin is an antitumor agent that is used in combined medical therapy of melanoma. The drug acts by inhibiting the synthesis of nucleic acids in malignant cells, which reduces their activity and the degree of division. Therefore, the drug reduces the number of malignant cells and leads to remission. To obtain the effect, it is necessary to have long-term treatment with repeated use of drugs to completely remove the malignant cells and block their reproduction. Dosage of the drug is always calculated individually for each treatment cycle. The main principle of dosage for children is the calculation of the drug per square meter of skin area of the baby. This is determined by special tables that correspond to the age and mass of the child with respect to the body surface. Method of application of the drug intravenous with a clear dosage throughout the day due to the placement of the infusomat. The side effects of all antitumor drugs are very pronounced, because in addition to malignant cells they also act on the cells of the body. Therefore, there is a decrease in the activity of reproduction of the intestinal epithelium, stomach, blood cells, protective function of leukocytes.
2. Vincristine is a drug that is used in the treatment of malignant neoplasms. The main active ingredient of the drug is the plant alkaloid, which acts by disturbing the mitotic division of malignant cells due to the destruction of the tubulin protein. This drug is used in complex therapy with individual dosage for each child per square meter of body area. The method of use is only intravenous with the prevention of getting on the skin or outside the vein. Side effects are very frequent, the main ones are inflammation and ulceration on the oral cavity shell and tongue, gastritis, digestive disorders of the intestine, frequent inflammatory diseases of the pharynx, bronchi, anemia.
3. L-asparaginase  is a drug that is also used to treat malignant tumors in pediatric oncology. The drug acts by reducing the amount of asparagine needed for malignant cells to multiply. With a deficiency of such an amino acid, their mitotic activity decreases and the child enters remission. The method of administration and dosage of the drug is the same as for all antitumor agents. Side effects - frequent tonsillitis on the background of drug treatment, paresthesia, abdominal pain, motor disorders, fungal complications, decreased overall immunity and frequent viral-bacterial diseases.
4. Dakarbazine is a drug used to treat skin and soft tissue tumors that is used in pediatric oncology. The drug acts by inhibiting cell growth and reducing the activity of DNA synthesis. Method of application of the drug intravenous with individual dosage for each child per body area. Side effects of the drug are expressed in the form of hepatitis, necrosis of liver cells, toxic effects on the kidneys, reducing the level of all cellular structures of the blood and affecting the growth of the child.

It should be clearly stated that for the treatment of melanoma, like any other tumor, combinations of not less than four such antitumour agents are used. Due to different mechanisms of action of drugs, the maximum effect of reducing the number of malignant cells is achieved. But such treatment is prescribed only by a pediatric oncologist, with mandatory long-term treatment in a hospital. In Ukraine, the treatment of oncological children, including children with melanoma, is free until 18 years.

The use of antibiotics and antifungal agents against such cytostatic therapy is considered mandatory, as the child develops a state of deep immunosuppression. Use a combination of drugs or monotherapy with broad-spectrum antibiotics. Sometimes, interferon preparations are used to treat and prevent a viral infection.

1. Josamycin  is an antibacterial agent from the macrolide group. Among the known drugs has the maximum activity because of its structure. The drug acts on the cellular and intracellular forms of bacteria, so it can be used against the background of cytostatic therapy to prevent the development of diseases and lungs, and the gastrointestinal system, and external skin infections. The method of administration depends on the age and can be in the form of a suspension or tablets. It is prescribed for children older than 3 years and the dosage is 10 mg / kg / day on the first day, from 2 to 7-10 days - 5 mg / kg / day 1 time per day. Obligatory condition - on the background of such therapy, taking probiotics and treatment for at least ten days. Side effects of dzhozamycin - paresthesia, violations of skin sensitivity, numbness of the hands and feet, tremor, violation of the outflow of bile, as well as disperse phenomena. Precautions - do not use for cholestasis or cholelithiasis.
2. Fluconazole is an antifungal agent that is used to treat complications against the background of antitumor therapy in the form of fungal inflammation of the oral cavity, genital organs, skin, internal organs. When symptoms of fungal complications appear, it is recommended to start immediately with a dosage of the drug of 6 milligrams per kilogram of the child's body weight, and then on the fifth day you can reduce the dose by half. The method of use is an oral preparation in the form of tablets. Side effects can be in the form of a decrease in appetite, a violation of liver function, changes in the heart rate, an increase in temperature, a decrease in the level of neutrophils.

Vitamins children in chemotherapy are given in the form of injection forms, because they are very important for the normal development of healthy cells.

Physiotherapeutic treatment is not used in the acute period, it is possible to use different methods already at the stage of full recovery only on the recommendations of the doctor.

Operative treatment of melanoma in a child is used in the first stage of the disease, when the stage of melanoma invasion is the first or second. Then the surgical intervention can ensure the full recovery of the child. The volume of the operation is determined after a thorough examination and assessment of the condition of the lymph nodes. If the lymph nodes are intact, the amount of surgery is limited only by excision of melanoma within healthy tissues. The operation for children is carried out under general anesthesia. Thus it is necessary to spare the skin itself, and melanoma to be removed more deeply into the subcutaneous tissue. Mandatory surgical material is sent for histological examination to determine the degree of invasion and the nature of melanoma.

If lymph nodes are affected, surgical intervention is performed with excision of melanoma and removal of regional lymph nodes with subcutaneous tissue.

Radiation therapy for melanoma is often performed in combination therapy at the third or fourth stage. It can be performed before the planned surgery or after it on the background of chemotherapy. For treatment, close-focus X-ray therapy or gamma-therapy is more often used. Irradiation is performed locally and, if necessary, on the lymph nodes.

Alternative treatment of melanoma in children

Alternative treatment and the use of homeopathic medicines can not cure melanoma or any other malignant entity. But alternative methods are used against the background of drug therapy for better effect and prevention of the development of infectious and other complications. To this end, use herbs and alternative methods that increase overall immunity.

1. As a rule, children on chemotherapy have a poor appetite, which further reduces the immunity of the child and increases the risk of infectious complications. Therefore, in order to improve immunity and improve appetite, the following mixture is recommended. You need to take equal amounts of ginger root and orange peel and grate. After the gruel is mixed, add five tablespoons of honey to 200 grams of such gruel and mix everything. After that, you need to add three grated walnuts and let stand for four to five days. Take a teaspoon twice a day.
2. Treatment of melanoma with aconite is known for its effect on malignant cells and a decrease in the activity of their reproduction. To do this, take fifty grams of aconite grass and pour hot water, insist for two hours. Take it for twenty days, starting with one drop once a day and increasing the dose every day by one drop. Then after the twentieth day of treatment it is necessary to reduce the dose of the drug according to the same scheme. So the course of treatment is forty days.
3. For the prevention of fungal lesions against the background of the treatment with melanoma, it is recommended to rinse the oral cavity of the baby with a solution of calendula after each meal.

Treatment of melanoma with herbs is not proven, but this method is widely used because such herbal infusions help to normalize digestion, appetite, and also some of them normalize the processes of cell division.

1. Infusion from the collection of herbs is good for taking sick children on melanoma to improve digestion and appetite. For infusion it is necessary to take 20 grams of coriander, 20 grams of elecampane and twice as many leaves of nettle as dioecious. Such a solution should be boiled for half an hour and taken on a spoonful three times a day after meals.
2. In the treatment of melanoma, the effectiveness of white birch bark is proven because of the high content of antioxidants and tannins. To prepare the infusion, boil the bark bark on a slow fire for two hours, and then the broth that is formed, dilute with warm boiled water twice and take a teaspoon up to five times a day.
3. Elder, fucker and centaury take a hundred grams of each plant and pour hot water. When the solution cools down add honey and drink instead of tea.

Homeopathy in the treatment of melanoma can be used to achieve remission. Drugs can be used to improve the immune status and normalize the general condition, prolong the period of remission. The most effective way to cope with melanoma is with concomitant immunotherapy. The main homeopathic remedies in the treatment of melanoma, which have the following effects:

1. Arsenicum album is a homeopathic remedy that is used in the complex therapy of melanoma in children, which is located on the face and is accompanied by a sharp consumption of body weight. Dosage in case of taking drops - one drop per ten kilograms of the child's body weight once a day. Side effects are possible in the form of hyperemia of the skin of hands and feet, as well as sensation of heat. Precautions - do not use in combination with preparations of bee origin.
2. Acidum Fluoricum is an inorganic homoeopathic preparation based on phosphoric acid. The effectiveness of the drug has been proven by many studies, especially in the treatment of melanoma in older children and adolescents. The way of using the drug depends on the form. Dosage in case of taking drops - one drop per year of life of the child, and when taking capsules - two capsules three times a day. Side effects - burning tongue, sore throat or abdominal pain that passes if you drink milk. Precautions - do not use if you have gastritis.
3. Nosodes are a homeopathic remedy of natural origin. The way of application of the medicine is enteral. Granules need to be chewed up to complete dissolution, it is not recommended to swallow whole. Dosage is two granules twice a day. Side effects can be in the case of a combination with iodine preparations - then there may be allergic manifestations. Precautions - it is impossible to use the drug in case of severe diarrhea in the child.
4. Silicea and sepia - the combination of these drugs in appropriate dilutions allows for effective treatment, especially with severe child asthenia and enlarged lymph nodes. The way of using medicines for children in the form of homeopathic drops and dosage is four drops twice a day in half an hour after eating at the same time. The course of treatment is three months. Side effects can be in the form of dizziness, so you need to take the medicine after eating.

Alternative therapies are diverse, but they can not be used as priority treatment methods.

[37], [38], [39]

Prevention

Preventing the development of melanoma in children is very relevant to date, as the culture of the tanning process of small children has changed slightly. Parents even for a year go with young children to rest. But children under three years are strictly forbidden to simply sunburn in the sun, especially during active hours of ultraviolet radiation. It is necessary to hide children and do not leave tanning intentionally, because their thin skin is not protected and is not able to synthesize melanin so well. Therefore, the main measure of prevention of melanoma in children is to avoid such an active sun. If your child has many birthmarks, you need to carefully monitor them constantly and record any changes in them, because this can be the main symptom of the disease. All other preventive measures are also nonspecific and consist in avoiding other possible harmful factors, especially when a woman is pregnant.

[40], [41]

Forecast

The prognosis for survival in melanoma in children is not very favorable, as the five-year survival rate ranges from forty to fifty percent. Remission with timely treatment occurs in 40% of patients.

Melanoma in children is a very rare disease, which is good to the extent of high malignancy of this type of pathology. But it's also not very easy to identify this pathology for a doctor in time, until the parents themselves pay attention to the state of health of their child. Therefore, if there are any changes in birthmarks in children who have not been there before, you should always contact the doctor.

[42], [43], [44], [45]