Malignant melanoma (pigm./amelanot.)

Black skin cancer, melanoma, malignant melanoma (pigmented or amelanotic).

Malignant epidermal neoplasm originating from melanocytes, regardless of pigmentation.

Switzerland ranks among the countries with the highest incidence of malignant melanoma worldwide. The age-standardized incidence currently stands at approximately 19 per 100,000 inhabitants per year. Over the past decades, a continuous rise in incidence has been observed, though this has stabilized around 2025, particularly in younger age groups. The median age at diagnosis is around 55 years. Mortality is slightly higher in men, although women are more frequently affected.

• Superficial spreading malignant melanoma (SSM)
• Nodular melanoma (NM)
• Lentigo maligna melanoma (LMM)
• Acral lentiginous melanoma (ALM)
• Amelanotic melanoma (any subtype can be non-pigmented)
• Desmoplastic melanoma
• Melanoma of unknown primary (occult primary)

Malignant melanoma results from a complex interplay of genetic predisposition and environmental UV exposure. Risk factors include fair skin types (Fitzpatrick I–II), a high number of common or atypical nevi, childhood sunburns, tanning bed use, and familial melanoma syndromes (e.g., CDKN2A mutation, dysplastic nevus syndrome). Around 50% of melanomas harbor a BRAF-V600 mutation; others show NRAS, NF1, or triple-wild-type profiles. UV-induced DNA damage (e.g., C→T transitions) is a key mutagenic driver in sporadic cases.

Melanomas typically present as new or changing skin lesions with asymmetry, irregular borders, color variation, and a diameter ≥ 6 mm. Women are more frequently affected on the legs, men on the upper back and trunk. Amelanotic variants may appear erythematous or skin-colored and are often difficult to diagnose. Early metastasis may occur via lymphatics (satellite and in-transit metastases), followed by hematogenous spread to organs including the lungs, liver, brain, skin, and bones.

• Thorough medical history: personal and family melanoma history, UV exposure, skin type, number of nevi
• Full-body skin and mucosal examination including lymph node status
• Dermoscopy: ABCDE rule, “ugly duckling” sign, and two-step algorithm
• If melanoma is suspected: prompt complete excisional biopsy for Breslow thickness assessment
• Incisional biopsies (punch or shave) only in selected cases (e.g., inoperable site or diagnostic uncertainty)

Preferred sites include sun-exposed areas such as the face, neck, arms, and legs. ALM typically occurs on palms, soles, and subungual regions. LMM is most frequently seen on the face of elderly patients.

Patients often report a newly developed or changing lesion. In high-risk individuals, suspicious nevi are often self-detected. Approximately one-third of melanomas are diagnosed by dermatologists during skin screenings.

Histopathology reveals atypical melanocytes spreading along the dermoepidermal junction and/or in the dermis. Key immunohistochemical markers include S-100, MART-1 (Melan-A), HMB-45, and IMP3. MIB-1 (Ki-67) is used as a proliferation index. CD10 overexpression may indicate a poor prognosis. Classification follows AJCC 8th edition (T-, N-, M-category, ulceration, Breslow depth).

Common complications include diagnostic delay, particularly in amelanotic or acral melanomas, and incomplete initial excision without sentinel lymph node biopsy, which may compromise lymphatic drainage and subsequent management.

Prognosis strongly depends on the stage at diagnosis. Early-stage melanomas (Breslow < 1 mm, no ulceration) show 10-year survival rates exceeding 95%. Advanced-stage patients benefit significantly from immune checkpoint inhibitors and targeted therapies, resulting in markedly improved long-term survival.

Effective prevention includes strict UV protection (shade, clothing, SPF ≥ 50), avoidance of tanning beds, and early detection through regular skin checks. Public education campaigns increasingly target populations with limited health literacy. Annual dermatologic screening is recommended for high-risk individuals.

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