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},
"code": "D03",
"name": "Меланома in situ",
"icd_name": "Меланома in situ",
"gender": 0,
"age_min": 15,
"age_max": 100,
"cause": [
3,
0
],
"periodicity": 1,
"slug": "d03_melanoma_in_situ",
"lead": "Нарушение здоровья, относящееся к группе новообразования in situ",
"description": "Меланома in situ – это злокачественное новообразование кожи, развивающееся из клеток меланоцитов, развивающееся в пределах верхнего слоя кожи - эпидермиса. Чаще всего развивается на открытых участках тела, которые больше всего подвержены ультрафиолетовому облучению.",
"etiology": "<p>К предрасполагающим факторам, способствующим развитию меланомы, относят:</p>\r\n<ul>\r\n<li>инсоляция солнечными лучами кожи;</li>\r\n<li>особенности кожи – белая, с трудом поддается загару, солнечный ожог развивается за 30 минут воздействия ультрафиолетовых лучей;</li>\r\n<li>невусы (родинки) – доброкачественные новообразования на коже, вырабатывающие меланин – кожный пигмент;</li>\r\n<li>травмирование родинок;</li>\r\n<li>генетическая предрасположенность – наличие у родственников старшего поколения меланомы;</li>\r\n<li>перенесенный рак кожи;</li>\r\n<li>предраковое заболевание кожи – пигментная ксеродерма;</li>\r\n<li>пожилой возраст;</li>\r\n<li>расовая принадлежность человека. Согласно статистике ВОЗ, чернокожие в 4 раза реже страдают от меланомы, чем европеоиды;</li>\r\n<li>наличие сопутствующих хронических заболеваний, которые приводят к снижению общего иммунитета человека.</li>\r\n</ul>",
"pathogenesis": "<p>При изучении процессов возникновения и развития меланом кожи следует учитывать, что эта опухоль является уникальной для изучения вопросов ее канцерогенеза, так как более 50% первичных меланом кожи развивается на фоне предсуществующих пигментных невусов, что позволяет расценивать последний как факультативный предрак, и так как наиболее важными экзогенными этиологическими факторами этой опухоли являются УФ-радиация и травма невусов.</p>\r\n<p>Механизм канцерогенного действия УФ-радиации может заключаться в образовании в нормальных клетках высокоактивных свободных химических радикалов. В основе возникновения опухоли лежат процессы повреждения этими радикалами ДНК клетки, нарушение ее нормальной репарации. Последовательность процессов возникновения меланомы кожи под воздействием УФ-радиации можно схематически представить в следующем виде: УФ-радиация- меланобласты, меланоциты или невусные клетки - повреждение ДНК клетки - нарушение дифференцировки клетки - изменение белковой структуры клетки с возникновением новых мембранных антигенов - гипореактивность - бесконечно долгое размножение (опухолевый рост). Вероятно, такой механизм канцерогенеза меланом кожи является наиболее коротким во времени, так как в данном случае отсутствует длительная пролиферация нормальных клеток и тканей. Клиническим подтверждением возможности «включения» этого механизма канцерогенеза является факт более частого возникновения меланом после однократного и интенсивного воздействия УФ-радиации (солнечного ожога).</p>\r\n<p>Напротив, механизм канцерогенного действия травмы предсуществующих пигментных невусов включает в себя пролиферацию тканей в ответ на их повреждение, но сама травма не приводит к развитию опухоли. Доказано, что клетки в состоянии пролиферации обладают повышенной чувствительностью к канцерогенному воздействию и особенно уязвимы, находясь в фазе митотического цикла. Поэтому интенсивное размножение (пролиферация) клеток может привести к их неопластической трансформации. Последовательность процессов возникновения меланом кожи в результате травмы предсуществующих пигментных невусов можно схематически представить в следующем виде: повреждение - невусные клетки - воспаление и пролиферация поврежденной ткани - длительная пролиферация + воздействие эндогенных канцерогенных факторов (иммунологических, эндокринных, нейрогенных и др.) - нарушение структуры ДНК клетки - нарушение дифференцировки клетки - изменение белковой структуры клетки с возникновением новых мембранных антигенов - гипореактивность - бесконечно долгое размножение (опухолевый рост).</p>\r\n<p>Что касается действия эндогенных канцерогенных факторов меланомы кожи, то, очевидно, что точкой их приложения являются длительно пролиферирующие нормальные клетки и ткани, которые под воздействием этих факторов могут трансформироваться в опухолевые.</p>",
"diagnostics": "<p>Дерматоскопия -макроскопический осмотр образования при помощи дерматоскопа.</p>\r\n<p>Биопсия с последующим гистологическим анализом. Гистологическая диагностика представляет собой осмотр микропрепарата (тончайший срез исследуемого образца), подвергшегося специфической или неспецифической окраске. Помимо окраски с целью определения клеточного или тканевого атипизма, применяются также иммуногистохимический и иммуноферментный анализы</p>",
"treatment": "<p>Основным методом терапии является локальное иссечение первичной опухоли до фасции. Количество иссекаемых тканей зависит от распространенности опухолей и рассматриваются индивидуально, обычно с небольшим захватом здоровых тканей. Лекарственная терапия меланомы in situ проводится редко, только при гистологической верификации метастазирования опухоли. Поскольку к химиотерапии рак кожи в последние годы всё более устойчив, а химиопрепараты крайне токсичны, активно развивается иммунотерапия. Для лечения прогрессирующей меланомы используют препараты на основе альфа-интерферонов, интерлейкина и моноклональных антител.</p>\r\n<p>Третий вид терапии злокачественных опухолей – лучевая. Облучение назначается до операции с целью уменьшения объема хирургического вмешательства либо после операции.</p>\r\n<p>Комбинацию и методы врач подбирает индивидуально исходя из существующих особенностей меланомы in situ в каждом конкретном случае.</p>",
"prevention": "<p>Чтобы предотвратить переход доброкачественного процесса в злокачественное, люди входящие в группу риска должны регулярно наблюдаться у врача. Любыми видоизменения родинок, усиление пигментации, увеличение родимых пятен в размерах, уплотнение невусов должны стать поводом немедленного обращения к врачу. Люди, на теле которых множество родинок и невусов должны внимательно относиться к своему здоровью. Необходимо избегать попадания прямых солнечных лучей на места скопления родимых пятен, не допускать повреждения образований и регулярно посещать косметолога в целях профилактики. </p>\r\n<p> </p>",
"clinical_picture": "<p>Меланома in situ характеризуется появлением следующих клинических симптомов:</p>\r\n<ul>\r\n<li>Усилением пигментации пятна, его ростом и выраженным затвердением. В отличие от доброкачественных родинок, форма in situ не имеет осевой симметрии, ее очертания неровные. Пигментированное пятно состоит из мелких скоплений. Если у доброкачественных родинок цвет всегда равномерный, то у радиальной меланомы он может сочетаться светло-коричневым и песочным оттенками.</li>\r\n<li>Появление красного ободка вокруг меланомы и застойных явлений</li>\r\n<li>Появление пигментных разрастаний в виде лучей, отходящих от меланомы в разные стороны.</li>\r\n</ul>\r\n<p>В некоторых случаях первым клиническим симптомом прогрессирующей меланомы in situ является увеличение крупных лимфатических узлов, тогда как давно существующая родинка или невус на поверхности кожи не изменяется по своей окраске и в размерах. Прогрессирующее увеличение родинки или невуса на поверхности кожи, а также его затвердение и изменение окраски является первым симптомом того, что заболевание перешло в злокачественную форму течения.</p>\r\n<p>Очень часто рядом с растущим пигментным пятном начинают появляться различные плотные узелки усиленной пигментации. </p>\r\n<p> </p>",
"image": null,
"image_alt": null,
"standard_type": 3,
"danger": 1,
"published": 2,
"parent": null,
"block_rubric": 36,
"standards": []
},
{
"id": 9168,
"symptoms": [
{
"id": 55,
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