Melanoma
Melanoma is a malignant neoplasm originating from melanocytes in the skin or other pigmented tissues (e.g., mucosa, uvea). Although it accounts for a relatively low proportion of all skin cancers, it exhibits high aggressiveness, early metastatic potential, and significantly elevated mortality.
Major risk factors include:
- Ultraviolet radiation exposure: Prolonged or intense exposure (especially intermittent high-dose UV during peak hours) markedly increases risk through cumulative DNA damage in melanocytes.
- Fair skin phenotype: Individuals with Fitzpatrick skin types I–II, freckling tendency, red/blonde hair, blue/green eyes, or history of frequent/severe sunburns are at substantially higher risk.
- Melanocytic nevi: High total body nevus count (>50–100 common nevi), atypical/dysplastic nevi, or congenital melanocytic nevi (especially giant congenital nevi) confer elevated lifetime risk.
- Family and genetic predisposition: First-degree relatives with melanoma increase risk 2–8-fold; germline mutations in high-penetrance genes (CDKN2A, CDK4, BAP1, POT1, TERT promoter, MITF E318K) or moderate-risk genes significantly heighten susceptibility.
- Immunosuppression: Organ transplant recipients, patients on chronic immunosuppressive therapy, or those with HIV/immunodeficiency syndromes have markedly increased incidence and more aggressive disease behavior.
Early detection through regular total-body skin examination, dermoscopy, sequential digital monitoring, and prompt biopsy of suspicious lesions, combined with comprehensive nursing intervention, is critical for delaying disease progression, optimizing therapeutic outcomes, and improving long-term quality of life and survival.
Early-stage melanoma may present with subtle or atypical signs that evolve gradually. Classic clinical features (based on ABCDE criteria and additional warning signs) include:
- Changes in existing nevi: Deepening pigmentation, asymmetric enlargement, irregular borders, or rapid evolution of a preexisting mole.
- New pigmented lesions: Appearance of a dark brown/black nodule, plaque, or macule with heterogeneous pigmentation.
- Asymmetry and irregular borders: One half of the lesion dissimilar to the other; ill-defined, notched, or scalloped margins.
- Color variegation: Multiple shades within the same lesion (shades of black, brown, tan, red, white, or blue).
- Diameter >6 mm (or rapid growth): Though smaller lesions can be malignant, especially in nodular subtypes.
- Evolving nature: Any change in size, shape, color, elevation, or symptomatology over weeks to months.
- Surface changes: Ulceration, bleeding, crusting, or oozing (more common in advanced primary tumors).
- Symptoms: Pruritus, tenderness, pain, or burning sensation at the lesion site (present in a minority but highly suggestive when occurring).
- Metastatic manifestations: Regional lymphadenopathy, satellite/in-transit metastases, or systemic symptoms (fatigue, weight loss, cough, bone pain, hepatomegaly) indicating distant spread to lymph nodes, lungs, liver, brain, or bone.
Early recognition of cutaneous abnormalities through self-examination (using ABCDE rule), total-body skin examination by a clinician, dermoscopy, and prompt excisional biopsy of suspicious lesions, combined with timely nursing intervention and patient education, can dramatically improve prognosis and survival outcomes.
Diagnosis of melanoma employs a multimodal approach aimed at early detection, accurate histopathological subtyping, prognostic stratification, and formulation of individualized nursing care plans:
- Clinical and dermoscopic examination
- Regular total-body skin self-examination and physician-performed full-skin examination using the ABCDE rule and “ugly duckling” sign for early identification of suspicious lesions.
- Dermoscopy (epiluminescence microscopy/handheld or digital dermatoscopy): Significantly improves diagnostic accuracy by revealing pigmented network irregularities, atypical vascular patterns, and other melanoma-specific structures.
- Histopathological examination
- Excisional biopsy (preferred) or wide local excision with appropriate margins: Gold standard for definitive diagnosis.
- Pathological reporting includes Breslow thickness (primary prognostic factor), ulceration status, mitotic rate, microsatellitosis, lymphovascular invasion, tumor-infiltrating lymphocytes, regression, and histological subtype (superficial spreading, nodular, lentigo maligna, acral lentiginous, desmoplastic, etc.).
- Staging imaging
- Ultrasound of regional lymph nodes (in clinically node-negative patients with thickness >0.8–1.0 mm).
- Contrast-enhanced CT chest/abdomen/pelvis, brain MRI, or whole-body 18F-FDG PET-CT: Indicated for staging in ≥ stage IIB–IIC or clinically node-positive disease to detect regional nodal and distant metastases (lungs, liver, brain, bone most common).
- Molecular and genetic testing
- Tumor somatic mutation profiling (mandatory in stage III–IV or high-risk resected disease): BRAF V600 (most common actionable mutation, ~40–50% of cutaneous melanomas), NRAS, KIT, and other driver mutations via next-generation sequencing panels.
- Additional biomarkers: Tumor mutational burden (TMB), PD-L1 expression (for immunotherapy selection), and germline testing for high-penetrance genes (CDKN2A, CDK4, BAP1) in patients with strong family history or multiple primaries to guide targeted therapy (BRAF/MEK inhibitors), immunotherapy eligibility, personalized adjuvant strategies, and long-term nursing/surveillance plans.
Nursing and supportive care strategies for melanoma can be divided into conventional modalities and personalized supportive approaches, aimed at delaying disease progression, preserving quality of life, enhancing immune function, and promoting long-term survivorship:
Surgical Management
- Indicated for localized primary tumors and regional disease; includes wide local excision with appropriate clinical margins (based on Breslow thickness) and sentinel lymph node biopsy (SLNB) for tumors ≥0.8–1.0 mm or ulcerated thinner melanomas; therapeutic lymph node dissection or neoadjuvant therapy in node-positive cases.
- Postoperative care emphasizes meticulous wound care, compression therapy for lymphedema (if node dissection performed), nutritional support, and psychological counseling to facilitate healing and reduce recurrence risk.
Radiation and Chemotherapy
- Radiation therapy: Primarily adjuvant in high-risk resected disease (e.g., desmoplastic melanoma, extensive nodal involvement) or palliative for unresectable local/regional or symptomatic metastatic sites.
- Cytotoxic chemotherapy (e.g., dacarbazine, temozolomide): Limited role due to low response rates; reserved for selected patients unfit for modern systemic therapies or in clinical trials; combined with rigorous hydration, antiemetic prophylaxis, and nutritional management to minimize myelosuppression and maintain physical function.
Targeted and Immunotherapy
- Personalized systemic therapy guided by tumor molecular profiling: – BRAF/MEK inhibitors (dabrafenib + trametinib, vemurafenib + cobimetinib, encorafenib + binimetinib) in BRAF V600-mutant advanced/metastatic disease. – Immune checkpoint inhibitors (anti-PD-1: pembrolizumab, nivolumab; anti-CTLA-4 + anti-PD-1 combination) as first-line therapy regardless of BRAF status, with adjuvant options in resected stage III–IV.
- Integrated with immune enhancement protocols, close toxicity monitoring (dermatitis, colitis, endocrinopathies, hepatitis), and nutritional support to optimize treatment tolerance and overall health.
Nutritional and Intravenous Supportive Therapy
- High-dose intravenous vitamin C, glutathione, essential amino acids, and trace elements to support antioxidant capacity, energy metabolism, immune competence, and tissue repair.
- Dietary recommendations: High intake of antioxidant-rich fruits/vegetables (berries, leafy greens, cruciferous vegetables), high-quality protein, omega-3 fatty acids, and whole grains; strict limitation of high-fat, high-sugar, ultra-processed foods, and alcohol to promote skin health, reduce inflammation, and support recovery.
Individualized Monitoring and Long-term Survivorship Care
- Risk-stratified surveillance with regular full-skin examination, regional lymph node ultrasound, and stage-appropriate imaging (CT/PET-CT/brain MRI); serum LDH and S-100 in metastatic disease.
- Development of patient-centered care plans with ongoing adjustment of nutrition, sun-protection education, lifestyle modification, and psychosocial support.
- Specialized nursing protocols for immunosuppressed patients, those with high-risk genetic syndromes, or history of multiple primaries to detect recurrence early, manage late effects (lymphedema, immune-related sequelae), and maximize long-term quality of life and survival.
