Subungual melanoma. Identification, development, result. Photo

pT2a Nx Mx acral lentiginous melanoma, vertical growth phase, degree of invasion according to Clark - IV, according to Breslow - 1.25 mm pT2a Nx Mx

The situation would look quite standard if there were not one “BUT”, this is a description of melanoma called:

SUBUNGUAL MELANOMA

How is this different from standard skin melanoma? Nothing, except that it is very difficult to diagnose (you will see this in the story), because... you need to either remove part of the nail, or remove the entire nail, and then there is the fact that subungual melanoma can easily be confused with a fungus.

So, a beautiful girl named Ksyusha writes to us. On her own initiative, for which she is expressed huge gratitude, I just want to note one thing: people, if you want to send something, or somehow “contact” me, then use the form on the site (the link is at the top in the “my exploits” section, or the social network “VKontakte” because in I visit various Facebooks and Google Plus VERY rarely.

Hello, Vadik!

Finally I’m ready to write))) It all started during pregnancy (2010)— A light gray stripe appeared on the nail of the left thumb, I didn’t attach any importance (of course)), after a while there were several stripes, but it was pretty (and at that time I didn’t find anything bad about it on the Internet).

Four years later I finally came across an article about melanoma and went to a dermatologist, who, after looking through a magnifying glass and taking a piece of a nail for analysis, determined that it's a fungus. “Phew, fungus,” I thought and was in no hurry to get treatment, because my husband and I were planning a second child, and antifungal drugs were not an option for us. A little later, of course, I was treated, but there was no effect, which did not bother my dermatologist at all.

All in all, summer 2015- I'm at a consultation in the city oncology center, where they looked at me with one eye and said: “ You have a wart, remove the nail“, removed by a surgeon at the clinic, somehow no one thought about histology.

I went again to the oncology center (having already read about melanoma, I tearfully asked to be examined somehow, but) - " This is 100% fungus, see a dermatologist“, I continued to run to dermatologists ((

December 2015 I was finally looked at through a dermatoscope and sent to the Cancer Institute to see Professor Korovin. First, my nail bed was cut out, and after histology, my finger was removed.

I’ve been injected with interferon for a year, I’m running to ultrasounds, I had a CT scan with contrast in March 2016, a little later I’m thinking of doing a PET scan, I also want to get tested for mutation ( may I never need it, but let him lie). The case, as I understand it, is truly rare. Of course, it’s my fault in the first place, I delayed it, but the doctors are also still... I hope that everything will be OK.

Thank you for your blog. In reality, I learned 20% of the information on this topic from scientific articles, 80% thanks to you. Thank you! Doctors don’t tell ANYTHING (((Maybe my story will save someone’s life. Health to all of us!!!)))
P.S. My husband and I divorced in 2015, now I’m even afraid to imagine what could have happened if there had been a second pregnancy. Everything that is not done is for the better)))

This is what the histology result looks like (in Ukrainian first, since citizens of this country are in second place after Russians in terms of blog traffic):

Microscopic description

The material has skin strips from a section of the nail bed with nails, with melanocytic new creations, with unclear boundaries, with the appearance of crowded plump cells, both in the epidermis and in the dermis. In the epidermis, there is a marked proliferation of atypical melanocytes, growing from the epidermal-dermal junction, especially in the form of single cells and different groups of melanocytes (currents). Melanocytes with signs of dim and severe cytological atypia, hyperchromic and vesicular nuclei

one basophilic nucleus, mitotic figures singly (1 per 1 mm2). In the epidermis there are signs of pronounced pagetoid proliferation of plump melanocytes. In the dermis there are puffy cells with diversification into the reticular ball of the dermis (stage IV of invasion after Clark). In the dermis, near the plump cells, there is visible lymphogistiocytic infiltration with a home of melanophages. There is no sign of perineural and lymphovascular invasion, no regression, no microsatellite metastases are detected. Thus, the results of histological examination indicate acral lentiginous melanoma, vertical phase of growth, stage of invasion according to Clark - IV, according to Breslow - 1.25 mm (ICD-O code 8744/3). For the AJCC (2009р)-рТ2а Nx Mx system.

So that you don’t have to bother and copy the text into Google, here’s the translation right away:

Microscopic description

The material contains a piece of skin from the area of ​​the nail bed with a nail, with a melanocytic neoplasm, with unclear boundaries, with the presence of accumulations of tumor cells, both in the epidermis and in the dermis.

In the epidermis, a pronounced proliferation of atypical melanocytes located along the epidermal-dermal junction is determined, mainly in the form of single cells and small groups of melanocytes (folders). Melanocytes with signs of moderate and severe cytological atypia, hyperchromic and vesicular nuclei with one basophilic nucleolus, single mitotic figures (1 per 1 mm2).

The epidermis shows signs of a pronounced pagetoid spread of tumor melanocytes. In the dermis, tumor cells spread into the reticular layer of the dermis (stage IV invasion according to Clark). In the dermis around the tumor cells, focal pronounced lymphohistiocytic infiltration with an admixture of melanophages is determined. There are no signs of perineural and lymphovascular invasion, no regression, microsatellite metastases are not detected.

Thus, the results of the histological examination correspond to acral lentiginous melanoma, vertical growth phase, degree of invasion according to Clark - IV, according to Breslow - 1.25 mm (ICD-O code 8744/3). According to the AJCC system (2009) -рТ2а Nx Mx.

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Well, actually. All that remains is to wish Ksyusha that the results of the mutation test will never be useful to her and once again say a huge thank you for such promotion of early diagnosis and early action.

I can’t say for sure whether amputation would have been required if melanoma had been diagnosed 3-5 years ago. Judging by such a long development of the disease, it would probably be possible to get by with a less radical intervention. I judge by Masha, who in Chelyabinsk was threatened with chopping off everything that was possible and not possible, and as a result, she has been galloping around Germany like a gazelle for two years: Treatment of melanoma in the Russian Federation and Israel. Review. Photo

Be that as it may, the conclusion is completely standard: don’t run “this thing.” Yes, you and I are not immune from crooked eyes and hands growing from “the same place,” but first we need to at least see a doctor on time!

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But that is not all. Seeing the name “Cancer Institute in Kyiv” and the surname Korovin, I simply could not help but ask the question:

Yes, it's him and his team. Didn't tell NOTHING.

Let me explain for those who either came here for the first time or are simply not in the know. The site you are reading now appeared globally after I discovered an article on the above-mentioned Ukrainian site in 2011. At that time, in the Russian-language segment of the network, this was the only mention of how to prevent the spread of melanoma through the lymphatic system.

But, unfortunately, I can note that, as I have seen more than once, the “brothers” turned out to be more theoreticians than practitioners, because this is not the first time that this institution does not tell patients anything about the procedure (or they simply don’t have ability to carry it out, so they remain silent).

Well, that's it now, don't get sick!

Subungual melanoma is a rare form of cancer that is diagnosed in 3% of women and 4% of men of the total number of cancer patients. This type of oncology can be localized on any finger of the limb, but often affects the thumbs and index fingers. Melanoma is characterized by rapid development and rapid onset of metastasis. At an early stage, almost all patients mistake it for a regular bruise and bruise, since the initial course of the disease is often asymptomatic. The prognosis for detecting a tumor at the last stage is poor.

What is nail melanoma and where can it appear?

Melanoma under the nail is a malignant oncological tumor, subtle and very insidious, capable of quickly spreading cancer cells throughout the body (metastasize). It is formed from melanocytes - special cells that affect the pigmentation of the skin and other integuments of the human body.

A malignant tumor forms under the nail plate on the big toes, less often on the hand (other fingers are extremely rarely affected, for example, the little finger on the fingernail), and can also be on the skin, but does not affect the palms and soles. Elderly people (from 50 to 80 years old) are most often affected, but now the disease has “become younger” and has begun to affect young people, and sometimes even children. Features of melanoma of the nail plate of the big toe or hand are:

• asymptomatic in the first stages;
• accelerated progression and growth (it can go from the initial stage to the last in a few months);
• active metastasis;
• problematic diagnosis (difficult to distinguish from injuries and other diseases).

People most likely to develop cancer on the big toe or upper limb are:

• people with naturally fair skin;
• fair-haired, especially red-haired;
• people with many age spots and moles on the body.

The neoplasm can be localized not only under the nail, but also on the skin nearby. Visually, it looks like a darkish (almost black) spot with fuzzy edges and an asymmetrical shape.

Its color can vary from brownish to red-black, and tumors can also be observed in shades of brown, pink, purple and even colorless (in 15% of cases).

External causes and internal factors of tumor occurrence

Scientists to this day do not know what exactly triggers the process when healthy cells degenerate into malignant ones and when pathological cells can form uncontrollably (this is how cancer grows). Often, melanoma of the toenail or hand nail develops in people with an inherited genetic predisposition after regular injury to the same area or after a serious, long-healing injury. A predisposition to malignant processes in the body is transmitted from close relatives. Additional provoking factors may be:

• numerous moles, pigment spots on light skin;
• age over fifty years;
• immunodeficiency due to chronic viral and bacterial infections;
• frequent exposure to ultraviolet light (solar or artificial).

The presence of addictions (smoking, alcohol addiction), autoimmune and other chronic dangerous diseases increases the likelihood of getting sick.

Stages of development

There are four stages of malignant melanoma. In each of them, the tumor behaves differently and manifests itself with different severity.

Stages and symptoms:

1. Asymptomatic. Melanoma of the nail plate does not penetrate the tissue more than a millimeter (it grows deeper), which is why it does not bother even when pressed. The first signs are subtle, the tumor can be noticed only by external signs - it looks like a dark brown, brown or black spot under the nail, the plate itself is smooth and undamaged. Metastases are not observed at this stage.
2. The tumor begins to actively grow, itch, hurt and deepen by two millimeters or more. You can notice damage in the form of cracks and ulcers, which is why the stain changes color - it becomes lighter or darker. No color change is observed if the tumor is light. At this stage, there are no metastases either, which means the disease is still treatable.
3. Nail melanoma deepens by 4-5 mm. The ulceration of tissues under the nail and adjacent ones begins, as well as deformation of the nail and nail bed. Numerous cracks and irregularities form on the nail, the affected area hurts and itches. Metastasis begins, which causes the patient’s general well-being to deteriorate. Metastases affect the lymph nodes.
4. The size of the melanoma is more than five millimeters, metastases are actively occurring, and the entire phalanx of the affected finger is deformed. Metastasis spreads to organs and affects all vital systems of the body.

Possible complications and consequences

Nail melanoma is characterized by extremely rapid progression and, due to its asymptomatic course, is often detected in the early stages even in the presence of metastases.

One can only hope for recovery if treatment is started in the first two stages. Metastatic stages are difficult to treat and often result in death.

Metastases are very dangerous, as they affect other tissues, as well as vital organs:

• lungs;
• liver;
• kidneys;
• brain and bone marrow.

Diagnosis and treatment

If symptoms are detected, you should immediately contact a dermatologist and oncologist. Melanoma is often confused with hematoma and fungal infection of the nails. Diagnostics allows you to accurately distinguish diseases from each other, and it is carried out using:

• blood tests for cancer markers;
• dermatoscope (a device for examining a tumor);
• biopsy (a part of the affected tissue is taken and examined in the laboratory);
• ultrasound diagnostics, CT, MRI (can detect metastases).

The results of these tests will help the doctor make an accurate diagnosis and determine the stage, which is important for selecting effective therapy.

The main way to get rid of melanoma is to excise the affected area along with the nail and part of the epithelium. If the tumor is too large, then the phalanx or even the entire finger is removed. If nail melanoma is discovered at the penultimate stage, when regional lymph nodes are affected by metastases, then these nodes are also removed (the procedure is called lymphadenectomy).

In the later stages of the disease, chemotherapy, radiation therapy, and immunotherapy are additionally performed. If the treatment is successful, you will have to undergo regular examinations by an oncologist in the future, since melanoma on the finger of the upper or lower limb may recur.

Treatment prognosis

Nail melanoma grows quickly and is difficult to treat. Successful treatment is possible only at the beginning of the disease, when, unfortunately, few people go to the hospital. A cancerous growth under the nail, which actively spreads metastases to the lymph nodes and internal organs, almost always leads to death. This occurs 1-2 years after the onset of metastasis.

Sometimes an illness appears in the human body for no tangible reason, which is associated with the uncontrolled self-reproduction of cells. One of the varieties of such ailments is nail melanoma. The initial stage of the disease is not very noticeable and may resemble other destructive processes. Therefore, patients seek help at a later stage.

Features of the disease

In simple terms, nail melanoma is a type of cancerous tumor, which is characterized by aggressive development and a specific clinical picture. If we take all cancer diseases, then about 4 percent are due to this disease.

Medical statistics show that in most cases the thumb on the right hand is affected. The preliminary stage of the oncological process occurs hidden. It is not always possible to detect cancer by external parameters.

Most often, nail melanoma is stained with epithelial pigment. In this case, it becomes much easier to establish the correct diagnosis, even with a preliminary examination by a doctor. About 20 percent of malignant tumors do not have this color, which complicates diagnosis.

Reasons for appearance

Various factors can lead to degeneration of nail plate cells:

• the presence on the skin of benign neoplasms such as moles and other growths that began to form a tumor body;
• congenital epithelial defects with atypical growths present on the patient’s fingers from the very beginning of life;
• the course of an oncological process in any organs or areas of the body, leading to damage to the nail plate by metastases;
• formation of a chancre under the nail plate resulting from a fungal or viral infection;
• regular injury at the site of tumor origin under severe physical conditions;
• exposure of the surface of the fingers to direct sunlight.

The listed risk factors can give the oncological process an initial impetus. As a result, nail melanoma forms. Photos showing its development in later stages can no longer be confused with other diseases. From the appearance of the nail plate it immediately becomes clear that there is a cancerous formation.

Main symptoms

In case of cancer, attention should be paid to a number of important points. Although the disease can easily be confused with a common fungal infection, there are significant signs that help make the diagnosis.

Usually pay attention to the following symptoms of nail melanoma:

1. Tumor formation. Often a dense-looking growth of degenerated cells is formed. It is he who begins to destroy the structure of the nail plate. Pores appear on its surface, after which the layers separate.
2. Change in nail color. In fact, this is one of the most important signs of a pathological process. The surface may turn blue, black, brown or purple. If the surface of the nail has changed color without any noticeable damage, the patient should seek help from a medical facility.
3. The presence of a vertical stripe. As the tumor body grows, a clear vertical line often forms, dividing the surface into two parts. It most often appears in the center of the plate. The strip may change color over time. Everything will depend on the specifics of the course of the cancer.
4. Leakage of pus from under the nail plate. In later stages, severe inflammation begins. A large amount of pus is released. The use of anti-inflammatory drugs and antibiotics in this case does not give the desired effect.
5. Frequent pain at the site of the lesion. When you press on your finger, they become pronounced. During periods of regular exacerbations, pain intensifies even in a calm state. A distinct pulsation is felt in the area of ​​oncology.
6. from the base. As the disease progresses, the plate does not receive the necessary nutrition, so it begins to peel off from the finger. Only a soft cushion, modified by the ongoing oncological process, remains visible.

The presence of two or more signs allows the doctor to assume that the patient has developed melanoma of the toenail or hand. Sometimes mistakes do occur, for example, a specialist examining a patient confuses this ailment with panaritium, which belongs to the category of infectious diseases.

Types of tumors and characteristics

Melanomas can be of different types. The main types of such tumors are shown in the table:

Types of nail plate tumors

Characteristic

Superficial

Acral

Received the greatest distribution. With this development of events, cell changes largely affect the outer skin. Deep layers are affected only in the absence of timely treatment.

In all respects, the tumor is similar to the one mentioned above. It develops, affecting the same layers of skin. Its peculiarity is uneven pigmentation.

It begins to appear on the surface layers of the skin, but gradually grows inside. The nail takes the form of a dark spot. Most often observed in dark-skinned people.

Characterized by deep germination into epithelial tissue. The tumor is characterized by the most aggressive nature of the lesion.

Stages of the disease

In the first two stages, melanoma under the nail has quite limited dimensions. The growing cells do not yet affect deep tissues and internal organs. The risk of spread is not too high.

In total, there are four main stages of the disease, the main evaluation criterion of which is the thickness of the formation:

• At the first stage, the thickness of the formation is less than 1 mm. The surface of the nail has no obvious damage and no ulcers are found. There is no pain when pressed.
• At the second stage, the thickness reaches 2-4 mm. Small ulcerations appear. Often tubercles form directly on the nail plate.
• At the third stage, the thickness of the formation is 4 mm or more. Tumor cells have already reached regional lymph nodes, creating secondary foci there.
• At the fourth stage, it no longer matters how thick the tumor has reached. Metastases spread to various organs. The pain is very strong. The size of the tumor increases significantly.

As for pain, it can appear already in the second stage, when the thickness of the growth begins to reach 2-4 mm. However, this does not always happen. In some cases, pain does not occur until the very last stage, until the bone tissue of the finger begins to be completely affected.

Basic diagnostic options

It is important to accurately determine at the right time that nail melanoma has appeared. The initial phase of the disease is much easier to treat than the later phase. To identify a dangerous disease, special diagnostic measures are used:

• general study of urine and blood tests;
• conducting MRI;
• taking tissue for biopsy;
• transillumination of the nail plate with a special device;
• performing ultrasound examination;
• determining the presence of cancer markers;
• obtaining a puncture from the lymph nodes.

The listed options allow you to obtain certain information, but they are usually carried out in combination. After studying the results, a specific conclusion is made.

Treatment process

Before starting treatment for nail melanoma, the presence of metastases is determined. At the initial stages, the patient has the emerging tumor removed surgically. If necessary, healthy tissues located around the affected area are also affected. The phalanx is cut off only in advanced cases.

When metastases form, the effectiveness of treatment decreases sharply. The patient may additionally be prescribed radiation or chemical therapy. Sometimes lymph nodes must be removed.

Survival prognosis

When assessing the prospects for treatment of nail melanoma, the stage of detection of the disease plays an important role. Even if the patient has recovered, it is necessary to constantly monitor his well-being. There is a high risk of relapse of the disease. Sometimes even after several years the disease returns.

The five-year survival rate in the presence of a tumor as a percentage is expressed as follows:

• At the first stage - 95%.
• At the second stage - 70%.
• At the third stage - 30%.
• At the fourth stage - 7%.

Low survival rate in the last stages is due to the appearance of metastases, which can occur not only in the fingers affected by the disease, but also in other parts of the body.

Final part

To avoid complex and lengthy treatment for nail melanoma, it is necessary to adhere to preventive measures. You should limit your exposure to direct sunlight, and also avoid bad habits such as drinking alcohol and smoking tobacco products. If there are suspicious changes in the nail plate, you should immediately consult a doctor.

Cancer is one of the greatest problems of humanity, which is becoming more urgent every year. A tumor can appear anywhere in the human body and, as it develops, spread to large areas through metastasis. Skin cancer (and it also has several types) is one of the most common pathologies in oncological practice. But the championship in mortality in the first year of the disease is still held by one type of skin cancer - melanoma. True, melanoma often means a tumor of melanocytes on the surface of exposed skin, and not everyone suspects that such a tumor is possible in the nail area. Dark spots under the nail are often attributed to an injury with hemorrhage (bruise, hematoma), but in fact it may turn out to be a malignant formation - subungual melanoma.

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ICD-10 code

C43.3 Malignant melanoma of other and unspecified parts of the face

Epidemiology

Since cell degeneration occurs when they are damaged, the risk of developing nail melanoma is relatively low. Still, the cells of the nail bed are protected from damage by the dense nail plate. According to statistics, only 0.7-4% of tumor processes on the skin are diagnosed in the nail area.

At the same time, the risk of developing subungual melanoma on the hands or feet is approximately the same, which cannot be said about different fingers of the extremities. The big toe (especially on the toes) is the most susceptible to injury, so melanoma of this toe is the most common. By the way, in 4 out of 10 cases of nail melanoma, patients indicate injury in the recent past.

Most often, the disease affects adults. After 55-60 years, this figure is maximum. Subungual melanoma is unlikely to occur in children. Usually, a dark spot in the child’s nail area turns out to be a nevus, causing the appearance of a characteristic stripe (melanonychia) on its surface.

People with dark skin color (African Americans, Indians, Hispanics, Asians) are most predisposed to developing subungual melanoma.

In representatives of the dark-skinned race, the disease develops mainly against the background of melanonychia (deposition of melanin in the nail plate). Dark-skinned inhabitants of the planet have a tendency to form dark spots on the nail bed and in the nail plate, but often the pathology is not considered as an independent disease, considering it a symptom of other diseases, including subungual melanoma.

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Causes of nail melanoma

We have identified several factors that can lead to cell degeneration in a certain area of ​​the skin: trauma, UV radiation, pigmented nevi, hereditary predisposition. Now we will try to consider the causes of melanoma under the nail in more detail.

Let's start with the fact that when we talk about nevi, we mainly suspect moles or birthmarks. In fact, hemangiomas (a non-malignant vascular tumor, which is usually detected immediately after the birth of a child), papillomas (a benign tumor, the cause of which is considered to be papillomavirus), and warts (viral tumors on the body) also have similar properties. Despite the fact that all such growths are benign in nature, their damage is likely to lead to a change in the properties of the cells and the malignancy of the process.

In principle, the cells of any growth on the skin of the finger, which has existed for many years without causing much concern to the owner, in the event of an injury, take the brunt of the blow, and therefore are damaged more than others. Moreover, the risk of developing malignant processes in this case is higher, and it does not matter where this growth is formed: on open skin or under the nail plate.

After the age of 40, some people develop individual shapeless dark spots on their skin that resemble moles. At the age of over 50, such marks appear in many people, and not just one at a time. This pathology is called seborrheic keratosis (senile keratoma), and it is caused by a violation of the production of keratinocytes in the basal layer of the skin. The neoplasm itself is benign. But over time, it begins to rise above the skin more and becomes more susceptible to injury. If such a spot appears on the toes, it can be squeezed or rubbed by shoes, suffer during impacts, etc., which can lead to cell degeneration. And there are quite a lot of such cases.

Risk factors

Risk factors for the development of subungual melanoma are any previously diagnosed types of skin and connective tissue cancer, as well as a hereditary predisposition to cancer. Even if a cancerous tumor is localized inside the body, it can metastasize to the area of ​​the nail fold, base of the nail, etc.

When we talked about dark-skinned people, we noted that their predisposition to subungual melanoma is associated with more frequent cases of melanychia. The frequency of this disease in Caucasians is less than 1%. But this does not exclude the appearance of subungual melanoma in people with fair skin. Regardless of the location of the lesion, melanoma is more susceptible to people with fair skin (usually blond or red hair and blue eyes), the presence of a large number of moles, and freckles on the face.

It is clear that the risk of malignant degeneration of cells is higher in people who like to sunbathe, especially during hours of increased sun activity, sunbathe in a solarium, and work outdoors. As for solar radiation, often skin burns received in tender childhood become an oncological problem in an adult, sometimes several decades later.

Fingers are areas of the limbs that are injured very often. But if even in everyday conditions, injuries to the fingers and nails are not a rare occurrence, then what can we say about production conditions, where the bulk of the work is done with the hands, or playing sports with a high risk of injuries to the toes (for example, football) and the development of melanoma of the big toe , because it is this finger that suffers most often and more than others.

It is clear that without provoking factors, no growth on the fingers or under the nail plate will turn into a malignant tumor. But how can we avoid these provoking factors if our living conditions, nutrition, and work already pose a risk of injury, poisoning of the body with carcinogenic substances, and exposure to sunlight? It turns out that the risk of developing subungual melanoma is quite high for each of us who lives in modern conditions, works in production and has forgotten the taste of natural products. The villagers benefit from this.

Pathogenesis

Symptoms of nail melanoma

Subungual melanoma is a disease whose symptoms are similar to some other diseases: nail fungus, hematoma after injury, subungual nevus, melanonychia, wart under the nail, paronychia or panaritium (inflammation or formation of pus in the area of ​​the nail fold and base of the nail). This is what makes diagnosing the pathology difficult.

And yet, what should alert a person? What signs may indicate that the appearance of a dark spot and inflammation in the nail area is not a simple consequence of an injury, but the beginning of a malignant process? Let's look at the symptoms characteristic of the onset of the disease:

1. The first sign of a possible pathology is a change in the color of the nail and the tissues under it or around the nail plate. This does not have to be the entire nail; most often, darkening is observed in some area of ​​the nail, for example, at its base. In this case, fabrics can be dyed burgundy, deep red, brown, purple-black and even blue.

It is clear that darkening of the tissue in the nail area is possible due to severe trauma with hemorrhages (bruise). But usually the symptoms of the injury go away within 10-12 days. If this does not happen, you should consult a doctor and diagnose the location of the damage.

Naturally, if the dark spot did not form due to injury, it must be examined.

1. If we are talking about non-pigmented melanoma, then tissue darkening may not be observed. And there is no pain in the early stages of the disease. For this reason, the non-pigmented form of the disease is usually diagnosed late, when its treatment is already very difficult and rarely brings good results.

But both pigmented and non-pigmented melanoma gradually grows and a longitudinal stripe appears on the nail plate above it. Most often, such a strip, which has a darker color compared to other tissues, is located strictly in the middle of the nail, but it happens that it is shifted to the right or left from the center of the nail plate. An identical situation is observed with melanonychia.

Over time, the stripe becomes darker and widens. This differs from a strip on the nail plate caused by hemorrhage due to microtrauma or taking certain medications, which does not change in size over time and moves as the nail grows. In the dark-skinned race, the appearance of a dark stripe is a certain feature, and does not always indicate melanoma.

The melanoma stripe expands until it covers the entire surface of the nail. Sometimes the process spreads to the lateral (side) nail folds, which also change the skin color to a darker one.

1. At first, the tumor cannot be felt and can only be suspected by a change in the color of the nail tissue, but as it grows, it thickens and begins to put pressure on the nail plate, causing its destruction. The nail peels off, becomes brittle, and cracks appear on it. The grip on the nail bed is reduced. All these signs are very similar to nail fungus.

As the disease progresses, ichor and pus begin to ooze from under the nail bed. The tissue around the nail becomes inflamed, and abscesses form between the nail plate and the lateral nail folds. From the outside it looks like a normal inflammation of the periungual fold (paronychia). If suppuration appears in this area, panaritium can be suspected. But in fact, everything can turn out to be much more dangerous, because the appearance of pus from under the nail and in the area of ​​adjacent tissues is one of the symptoms of subungual melanoma.

Next, ulcers form at the site of the abscesses, which gradually become larger in size. Attempts to treat the disease with anti-inflammatory and antibacterial ointments do not give results, because we are not talking about an infectious process. The sores may fester or ooze, they are quite painful, but do not heal, no matter what measures are taken.

If at first melanoma resembles a small tubercle, then over time it changes its shape to a mushroom-shaped one with a fleshy “cap” and a thinner stalk. This is a characteristic sign of melanoma, although again its similarities with papilloma are visible.

You need to understand that the malignant process tends to spread not only over the surface of the skin, but also inside the tissues. If at the first stage there is practically no pain when pressing on the nail, then as the tumor process spreads to other areas and deep into the bone, pressure on the finger will be accompanied by severe pain. When pus appears under the nail, the pain may be constant, throbbing.

It is clear that inflammation with the formation of pus and dystrophic processes in the nail disrupt the nutrition of the nail plate, as a result of which it is separated from the nail bed, on which the malignant process is actively progressing. But now he is no longer hidden from view, and there is no doubt about his character. True, treatment at this stage of the disease does not have such encouraging results.

Stages

Symptoms of melanoma may vary somewhat depending on the type of pathology and its stage. There is no strict classification by type regarding nail melanoma, but they distinguish:

• melanoma, which develops in the area of ​​the matrix (base) of the nail, then darkening of the nail in the lunula area is immediately observed,
• melanoma, which originates under the nail plate (in this case, a dark spot can appear anywhere on the nail and stretch into a colored stripe as the nail grows),
• melanoma of the skin near the nail plate (the spot appears on the periphery of the nail, but gradually spreads further).

You need to understand that all these signs apply to pigmented melanoma. In the non-pigmented form, external manifestations are not observed until brittle nails, pus and ulcers appear. Over time, you may also feel a lump under the nail.

As for the progression of the disease, the initial stage of subungual melanoma is more like a subungual hematoma with the appearance of a dark spot on the nail, which gradually lengthens and grows along with the nail. There are usually no other signs.

At the second stage of the disease, the nail is destroyed and purulent inflammation appears. By the end of the second stage, multiple ulcers are observed under the nail plate and next to it, from which ichor oozes. Next, the nail peels off.

It is known about the third and fourth stages of subungual melanoma that during this period the process of metastasis occurs. First, there is inflammation of the regional lymph nodes and their hardening due to the proliferation of malignant cells and individual foci of the tumor process in nearby tissues; subsequently, distant metastases appear, affecting the internal organs of a person.

Depending on how malignant cells spread: with the lymph flow or through the blood (lymphogenous and hematogenous route of metastasis), the disease will proceed slowly (in the first case) or aggressively, affecting large areas of the body in a short time (when spreading with the blood flow through blood vessels).

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Complications and consequences

A cancerous tumor is a terrible new growth, regardless of where it is found. After all, cancer cells not only multiply excessively, forming compactions that compress nearby organs and impair their functionality. They also poison the body and destroy healthy cells. Due to their fault, various malfunctions occur in the body, and when it comes to vital organs, the patient’s death occurs.

Typically, death is associated with a large tumor size or metastases to the heart, kidneys, and lungs. As long as the tumor is small and has not metastasized, it can be safely removed, but again it all depends on the extent of the process. Sometimes surgeons limit themselves to only removing the nail or the distal phalanx of the finger; in other cases, they have to remove the entire finger. If the process of metastasis has not been started, one can hope for a favorable outcome of treatment, otherwise malignant foci may subsequently appear in different parts of the body.

If malignant cells spread through the blood, the disease develops very quickly, and by the time it is diagnosed it can enter the third or fourth stage. First, a person suspects a nail injury with the formation of a hematoma, then he begins to treat the destruction of the nail and abscesses, considering them the machinations of fungi and bacteria, and when the treatment does not produce results, he comes to the doctor, who diagnoses the advanced stage of the disease, although perhaps only a couple of months have passed since the onset first symptoms.

The situation is not the best with non-pigmented subungual melanoma. At first it doesn’t show itself in any way, then a light-colored wart appears, lifting the nail. Over time, the wart acquires a specific mushroom-shaped shape, and it would be time to wonder what it could be. But as long as it does not hurt, few people begin to worry about its appearance. When pain appears, it turns out that the process has gone deep inside and affects the bones.

Diagnosis of nail melanoma

If you carefully study the symptoms of subungual melanoma, you will notice that there are virtually no specific symptoms by which the disease could be diagnosed with great accuracy. The neoplasm at different stages of development will resemble the clinical picture of many other diseases, which significantly complicates the diagnosis. And often it simply delays the moment of contacting a doctor and becomes the reason for delayed treatment without any guarantees.

Based on the appearance of pigmented melanoma, a doctor can only suspect oncology. To confirm the diagnosis, you will also need to prescribe a clinical blood test and a blood test for tumor markers. But again, a positive result only indicates the presence of a malignant process in the body and does not provide information about its localization. Perhaps the patient has an ordinary hematoma on his nail, which will be removed by mistake, but this will not relieve him of a tumor in another place that no one even suspected.

It is possible to confirm that a dark spot on the nail is melanoma using instrumental diagnostics. Of course, dermatoscopy comes to the fore, i.e. examining the spot under the nail using a special device - a dermatoscope. This modified microscope allows you to view even the stratum corneum of the nail plate to detect malignant cells underneath or exclude a diagnosis of cancer.

Digital dermatoscopy allows you to obtain an enlarged image of damaged tissue on a computer monitor and take a high-quality image for further study and consultation.

It is clear that at an early stage, when there are still few malignant cells, dermatoscopy may not detect them, especially if the study is carried out by a doctor with insufficient experience. The only way to completely confirm or refute the diagnosis of subungual melanoma is a biopsy, during which a tissue sample is taken from under the nail to a depth of 3 mm.

To obtain an informative sample in the area of ​​a dark spot at the base of the nail, you need to make a puncture or remove the nail plate. But it is best to remove not only the nail, but also the suspicious tumor and the adjacent areas of healthy skin. The fact is that a biopsy, i.e. disruption of tumor tissue can provoke even greater cell proliferation and tumor growth, which can also metastasize in a short time. In order not to risk a biopsy, it is necessary to take a biopsy sample from a remote area of ​​the nail, which includes the nail plate, the muscle tissue under it, subcutaneous fat, and sometimes the entire distal phalanx of the finger, if the process was widespread.

There is no need to worry about a removed nail or a wound in the nail bed. The wound will heal, perhaps even a new nail will soon grow. But it is better to remove the hematoma than to ignore the cancerous tumor or disturb it and cause metastasis. At an early stage of the disease, the likelihood of a complete cure is quite high.

If a biopsy confirms the diagnosis, it is important to understand at what stage the disease was detected and whether the tumor has metastasized. To detect metastases, they again resort to instrumental diagnostic methods: ultrasound examination, radiography, computed tomography and magnetic resonance imaging. If an increase in regional lymph nodes is observed, a puncture biopsy is necessarily performed to determine whether a change in the size of the lymphatic vessels is associated with the proliferation of malignant cells inside them.

, , , [due to the similarity of external signs and the nature of the lesion. A subungual wart may raise suspicion for an amelanotic melanoma, and a subungual hematoma may raise suspicion for a pigmented one.

In order to differentiate diseases and exclude incorrect diagnosis, it is very important to study the behavior of a spot or tubercle in the nail area from the patient’s words. With melanoma, they will definitely increase in size. Pay attention to the nature of the pain. The appearance of a dark spot that is not associated with injury and does not cause pain when pressed is highly likely to indicate its malignant nature.

Treatment of nail melanoma

As we have already said, cancer cells are highly resilient, so chemotherapy or radiation without removing the tumor can hardly guarantee the complete destruction of malignant particles. In addition, in order to accurately diagnose cancer based on the results of a biopsy, it is still more expedient and safer to first remove the tumor. So it turns out that surgical removal of subungual melanoma is the main method of its treatment.

If the tumor is relatively small and has not gone deep inside, sanitation of the phalanx is carried out with the removal of the nail plate and soft tissue under it to the depth of the tumor penetration, plus some part of the healthy tissue is captured. If the process has spread to the periungual ridges, even part of the finger tuft is removed, but the phalanx is preserved.

In the case of deep penetration of the tumor and metastasis into bone tissue, sanitation as a method of surgical treatment no longer makes sense and it is necessary to resort to amputation of the distal phalanx (less often a finger). Thus, it is possible to prevent the spread of cancer cells by hematogenous route.

If enlarged lymph nodes are detected after a biopsy and confirmation of the presence of cancer cells in them, lymphadenectomy is prescribed, i.e. excision of a lymph node affected by cancer. All this is done in order to block the lymphogenous path of cancer spread.

Other methods of treating nail melanoma are prescribed only after the tumor has been removed. We are talking about chemotherapy (drug treatment with potent drugs), radiation treatment, which is dosed irradiation of a certain area of ​​the body in the area of ​​the finger (if the tumor has metastasized, other areas of the body are also irradiated), taking immunomodulating vaccines and serums containing antibodies. Immunotherapy is effective for melanoma.

As for chemotherapy, treatment can be carried out with two types of drugs - cytostatics and cytotoxic drugs. The former inhibit the proliferation of cells and lead to their disintegration (death) due to the inability to divide, the latter lead to intoxication of cancer cells, as a result of which they die.

After removal of the tumor without metastases, local treatment with chemotherapy can be carried out (application of ointments, washing the wound with solutions, injecting drugs directly into the tissue of the affected finger). If the metastases have not spread beyond the finger, regional chemotherapy is performed, i.e. drugs are injected directly into the diseased organ. When metastases spread beyond the finger and spread to internal organs, systemic chemotherapy is required (drugs are administered intravenously or orally).

Usually, even such a complex and difficult to tolerate treatment gives good results only in the early stages of the disease. Further, it only slightly prolongs the life of patients and requires additional administration of painkillers, since the spread of a malignant process inside is always accompanied by severe pain.

Prevention

Oncologists believe that you need to pay close attention to any changes in the nail after injury. Such changes should be considered malignant until proven otherwise. This may seem strange to some, but such an attitude to the problem is justified. It's better to be safe than to die because of a neglected bruise that at some point turns into a cancerous tumor.

When we talk about the treatment of cancer, we rarely talk about long-term prognoses, because it is not always possible to completely get rid of cancer cells, moreover, the disease greatly depletes the body and makes it more susceptible to other diseases, for example, infectious diseases, which we have no strength to fight. no longer remains. The body is weakened not only by the disease, but also by chemotherapy or radiation therapy. Sometimes the tumor forms again, but in a different place.

Usually, when making any forecasts, they talk about a five-year survival threshold. It is considered that if the patient has not died within this time, i.e. the disease has not returned, there is a chance for a full recovery.

So, at the initial stage of subungual melanoma, the five-year survival rate is 75-88%, which is considered a high figure. The prognosis for the second stage is already much worse - about 60-70%. At the third stage, when metastases spread only to the lymph nodes, we can talk about only 40%, and then there is a high risk of relapse 5 years after surgery if the process is sluggish. When internal organs are damaged (stage 4), up to 85% of patients die within five years, and only a few cross this threshold.

It turns out that the sooner a patient seeks help, the greater his chances of a complete recovery if adequate therapy is prescribed. This suggests that you need to pay attention to any changes in the color or shape of the nail, the appearance of new nevi and seals on the fingers, the formation of longitudinal lines on the nail and their behavior. If there is a change in the color of the subungual nevus, widening of the stripe on the nail and thickening of the nail plate, you should definitely consult a doctor.

The only thing that remains for us is to closely monitor our health, be as careful and careful as possible, regularly examine our body for the presence of strange growths, bumps, pigment spots, pay attention to changes in the color and shape of moles, the appearance of dark inclusions on them, ulcers, cracks, changes in the shape and thickness of the nail. Only in this case is there a great chance of avoiding such a deadly disease as subungual melanoma. We should not think that if the pathology is rare, then it will not affect us. This attitude to the problem is fraught with great disappointment.

It is important to know!

Today, various neoplasms affecting the skin are becoming more common. Moreover, approximately 4-10% of them are malignant tumors. It affects people of different sexes with equal frequency. In most cases, the tumor does not form spontaneously.

Definition. Nevi in ​​the form of longitudinal melanonychia, located along the nail plate.

Age and gender. Nevus occurs at the same age as regular moles. There are no gender differences. Longitudinal melanonychia, caused by a melanocytic nevus or melanotic spot, can sometimes occur after 30 years of age.

Etiology and pathogenesis of nail bed nevus. Longitudinal melanonychia can be caused by the following reasons: increased melanin content in the cells of the basal layer of the epidermis due to excessive activity of melanocytes without increasing their number (melanotic spot and other factors); benign proliferation of melanocytes (lentigo, melanocytic nevus); melanoma growth. Longitudinal melanonychia in children is almost always a melanocytic nevus (borderline or mixed) or melanotic spot.

Clinic. A nevus, as a rule, is located on one finger in the form of a longitudinal brown or black line running along the nail plate, 1-4 mm wide.

Diagnosis of nail bed nevus is established according to clinical and anamnestic data, as well as during dynamic observation of melanocytic nevus of the nail bed. If there is any doubt about the benign nature of a subungual lesion, a biopsy is necessary.

Differential diagnosis of nail bed nevus. When longitudinal melanonychia occurs, it is necessary to carry out a differential diagnosis primarily between melanocytic nevus, lentigo, melanotic spot and subungual melanoma. In children, longitudinal melanonychia is usually represented by a benign pigmented lesion. Subungual melanoma in children is reported extremely rarely in the literature.

It was mainly detected in black children and people living in Asia. However, publications have now appeared on the occurrence of subungual melanoma in situ in fair-skinned children.

Melanocytic nevus of the nail bed of the first toe in the involution stage in a 54-year-old patient.
At the age of 11-12 years, a longitudinal pigment stripe appeared.
At the age of 35-40, it became discolored, but splitting of the nail plate occurred.

A. Tosti et al. in 2012 described 2 cases of this malignant process in a 6-month-old boy (skin phototype I) and an 11-year-old girl (skin phototype II). For clinicians, the presence of melanonychia in children represents a serious diagnostic challenge. This is due to the fact that there are no reliable clinical, dermoscopic and histological criteria that provide a clear distinction between benign pigmented lesions and melanoma in situ in children.

At benign melanocytic hyperplasia Children sometimes exhibit clinical and dermoscopic signs that are considered possible manifestations of subungual melanoma in adults.

In adults alarm cause stripes of heterogeneous color that have blurred lateral borders, as well as the presence of cracks and separation of the nail plate, rapid expansion of the stripe, an increase or decrease in pigmentation over time. These signs may occur in children with melanonychia lentigo and melanocytic nevus due to activation of melanocytes in the nail matrix.

They are at children are not considered indicators for surgical excision of the lesion, but require careful observation and possibly a biopsy. Other clinical signs also indicate subungual melanoma in adults: the appearance of pigmentation after 30-40 years (it appears suddenly and a traumatic factor is excluded); the strip has a triangular shape; pigmentation not only on the nail bed, but also on the surrounding skin; dystrophy or destruction of the nail plate with bleeding in the area of ​​pigmentation; localization on one and/or two and/or three fingers; patients have a history of melanoma.

Besides, differential diagnosis between benign melanocytic hyperplasia and subungual melanoma in situ in children is often a major concern even for pathologists because most studies in this area have been performed only in adults. In children with melanocytic nevus of the nail bed, mild migration of melanocytes into the overlying layers of the epidermis and cellular atypia are often present.

Differential diagnosis between melanoma in situ, melanocytic nevus and lentigo of the nail bed is based on the presence in melanoma of a large number of atypical melanocytes, fusion of nests and pagetoid spread of cells into the suprabasal epidermal layers. In addition, differentiation between these diagnoses is also carried out by quantitative histological characteristics: with melanoma in situ in adults, there is a high density of melanocytes per millimeter (> 40), such parameters were not assessed in children.

Besides, melanocytic nail bed is differentiated from other benign diseases that can cause longitudinal melanonychia. It may be the result of the production of melanin by melanocytes (without increasing their number) matrix in people with dark skin color (people of the Negroid race, Mediterranean origin and others). Racial melanonychia has a pigmentation width, usually from 1 to 4 mm, less often up to 6 mm. It usually occurs on two to five fingers, less often on one finger of the hand; on the feet, one to ten fingers can be affected.

Longitudinal melanonychia may be mycotic in nature. The strip width is generally less than 4 mm. It has white or yellowish shades, but there may be other colors (brown, orange). Two to five toes may be affected. Distal lateral subungual onychomycosis remains the most common form of fungal infection. Its main features are onycholysis with hyperkeratosis and various forms of dyspigmentation.

:
a - Marginal pigmentation of the nail of the fifth finger in a 52-year-old patient.
Pigmentation appeared 2 months ago and was differentiated from melanoma.
Melanoma most often occurs in the area of ​​the first toes, while the pigmentation has a different shade and is often found on the skin near the nail.
In the area of ​​the fifth toes, post-inflammatory hyperpigmentation is more often observed, caused by traumatic factors of tight shoes.
b - Marginal pigmentation of the nail plate in the area of ​​the first toe of the right foot.
It can be regarded as post-inflammatory hyperpigmentation after resolution of inflammation of the lateral nail fold when wearing tight shoes.

Longitudinal melanonychia cause injuries. Trauma resulting in hematoma remains the most common cause of melanonychia, which is usually dark brown or black in color. In addition, post-traumatic melanoma can form when wearing tight shoes due to repeated abrasions and friction. This melanonychia usually occurs on one finger. Nail pigmentation can also be caused by nail biting. This type of nail pigmentation gradually resolves after the traumatic factors disappear.

Longitudinal melanonychia may be associated with inflammatory skin diseases. This type of pigmentation can occur with lichen planus, psoriasis, and pustular diseases. Melanonychia can also be detected in Laugier-Hunzicker, Peutz-Jeghers syndromes, in patients with HIV infection, acanthosis nigricans, lupus erythematosus and scleroderma.

Longitudinal melanonychia occur as a result of the use of various drugs. Some drugs can activate melanocytes in the nail matrix and help increase the amount of melanin. This leads to the appearance of several longitudinal and/or transverse stripes on the nail plate of different colors from light brown to black. This may affect one nail or several. Pigmentation of the entire nail plate is possible. Drug-induced melanonychia most often appears 3-8 weeks after the start of use of this drug.

This pigmentation is usually reversible within 6-8 weeks, but may persist for several months after drug use is stopped. In addition, longitudinal melanonychia is caused by zidovudine (Retrovir), some chemotherapy drugs, psoralen, and antimalarials. Radiation therapy can also lead to subungual pigmentation.