1. Incidence – has increased fivefold in Germany since the 1970s4
The incidence of malignant melanoma depends on geographical location, local UV radiation, skin type and (leisure) behavior. In Germany alone, the incidence of malignant melanoma has increased more than fivefold since the 1970s.4 According to the Robert Koch Institute, more than 23,000 people in Germany are diagnosed with a malignant melanoma of the skin every year. This means that melanoma is now among the top 5 in the ranking of new cancer cases. The average age at diagnosis in Germany is 62 for women and 68 for men.5
2. Melanoma – risk of early metastasis
Melanoma is a malignant tumor that originates from pigment cells (melanocytes). In principle, it can occur anywhere, but it mainly manifests itself in the skin. The tumor is responsible for more than 90% of all deaths in patients with skin tumors and is characterized by early metastasis. The brain is more severely affected here than in all other malignant tumor entities.1,2
3. UV radiation – the most important exogenous risk factor
The most important risk factors for the development of a malignant melanoma include a light skin type and genetic/familial factors as well as the ultraviolet components of sunlight.4,5 Above all, severe sunburn in childhood and adolescence, intermittent sun exposure and regular visits to the tanning salon promote the development of melanoma.4,5
The classic visual sign of malignant melanoma is a change in the color, size, diameter, or general shape of a pigmented mole.
The change can occur over the course of months to years and can be gradual so that the person affected does not even notice it at first. Itching, tenderness, or other unfamiliar discomfort in the area of a nevus can also be related to the development of melanoma. Symptoms that may accompany the progression of the disease include bleeding and the occurrence of ulceration.
5. Diagnosis- the sooner the better
a. excisional biopsy
Excisional biopsy is the preferred form of biopsy when melanoma is suspected. It includes the complete removal of the suspicious skin change, including a safety margin of 1 to 3 millimeters from the surrounding tissue. As a rule, the excisional biopsy can be performed under local anesthesia.
b. incision biopsy
In an incisional biopsy, only part of the suspicious skin change is removed first. It is used for very large findings or for those located on parts of the body such as the face, palms of hands or soles of feet. At such cosmetically or functionally important sites, the diagnosis should be confirmed before the entire skin area is removed.
The histological examination of the removed tissue in the laboratory is currently the safest method of distinguishing between benign and malignant skin changes. If the suspected diagnosis of “malignant melanoma” is confirmed, this laboratory diagnostics, also known as “microstaging”, is used to carry out further tests that are decisive for the type of treatment.
Depending on the histological findings, a lymph node sonography is recommended. If distant metastases are suspected, the tumor markers S100ß and lactate dehydrogenase (LDH) should also be determined in the laboratory and imaging procedures such as magnetic resonance imaging of the head and whole-body sectional imaging (PET/CT, CT or MRI) should be carried out.2 Molecular diagnostics also plays an important role. Targeted therapies can be used for certain mutations. Around half of all patients with melanoma have a mutation in the serine/threonine kinase BRAF.8 A c-KIT aberration occurs much more rarely.9 In BRAF-negative patients, an NRAS mutation can be detected in about 15-20% of those affected.10
6. Staging – Crucial to prognosis and therapy
Staging is performed to assess tumor stage, following the AJCC (American Joint Committee on Cancer, 8th Edition) TNM classification.
The following properties are examined:
T – Tumordicke
N – number of affected lymph nodes
M – Presence and location of metastases in other organs
There are basically four stages:
Stages I and II include all tumors without metastases. That means the tumor is localized. In stage III, lymph nodes are already affected, in stage IV the tumor has already formed metastases in other parts of the body.
You have the option to download the current version of the TNM classification directly here to download.
7. Therapy – major advances in treatment options
Depending on the type of melanoma, the stage of the disease, and the age and general health of the patient, there are more and better therapies available today than there were a few years ago. This change is mainly due to the treatment options offered by targeted and, in a special way, immuno-oncological therapies. For the latter, this applies to both monotherapy and combination therapy.
On the one hand, patients in advanced stages of the disease can now be treated with more effective drugs. On the other hand, many more patients with an increased risk of recurrence can now benefit from adjuvant therapy that can reduce this risk.
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- Miller AJ, Mihm MC, Jr. Melanoma. N Engl J Med 2006; 355: 51-65.
- S2 guideline diagnosis, therapy and aftercare of melanoma. Version 2.1. October 2021. https://www.leitlinienprogramm-onkologie.de/fileadmin/user_upload/Downloads/Leitlinien/Hautkrebspraeventationsleitlinie_1.1/Version_2/LL_Prävention_von_Hautkrebs_Langversion_2.1.pdf
- Bristol Myers Squibb. Malignant melanoma – diagnosis and therapy. Available at: https://www.krebs.de/servlet/servlet.FileDownload?file=00P6M00001sjCGXUA2
- Robert Koch Institute. Report on the occurrence of cancer in Germany 2016. https://www.krebsdaten.de/Krebs/DE/Content/Publikationen/Krebs_in_Deutschland/kid_2019/kid_2019_c43_melanom.pdf?__blob=publicationFile
- Robert Koch Institute. Report on the occurrence of cancer in Germany 2018. https://www.krebsdaten.de/Krebs/DE/Content/Publikationen/Krebs_in_Deutschland/kid_2021/kid_2021_c43_melanom.pdf?__blob=publicationFile
- Public health portal in Austria. Skin cancer: melanoma. Retrieved on 06/24/2022 from: https://www.gesundheit.gv.at/krankheiten/krebs/hautkrebs/melanom
- Tas F. Metastatic behavior in melanoma: timing, pattern, survival, and influencing factors. J Oncol 2012: 647684.
- Davies H, Bignell GR, Cox C et al. Mutations of the BRAF gene in human cancer. Nature 2002; 417: 949-954.
- Goldinger SM, Masons C, Stieger P et al. Targeted therapy in melanoma – the role of BRAF, RAS and KIT mutations EJC Suppl 2013; 11:92-9
- Johnson DB, Puzanov I. Treatment of NRAS-mutant melanoma. Curr Treat Options Oncol 2015; 16: 15.
- Gershenwald JE, Scolyer RA, Hess KR et al. Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 2017; 67: 472-492.