Malignant Melanoma: Symptoms, Complaints, Signs

The following symptoms and complaints may indicate malignant melanoma (MM):

Leading symptoms

  • Pigmentary moles that change (ABCD(E) rule):
    • Asymmetry
    • Irregular boundary
    • Irregular color (Color)
    • Diameter > 5 mm
    • Sublimity > 1 mm

Associated symptoms

  • Bleeding
  • Rapid growth
  • Ulceration (ulceration)
  • Incrustations

Localization

  • In Europeans, the changes occur preferentially on the chest, back or extremities.
  • Most often affected in men and women are the torso and arms; in women, increasingly on the legs as well as the hip
  • The 5 most common localizations of melanoma.
    • Cheek 7%
    • Back 24 %
    • Torso front 14 %
    • Upper arms 17 %
    • Lower legs 7 %
  • Sex-specific localizations of melanoma (listed the sex more affected in each case).
    • Men
      • Back 29.65
      • Torso front 16.25 %
      • Capillitium (hairy scalp) 4.94 %.
      • Ear 3.1 %
      • Preauricular (“in front of the ear”) 3.6 %
    • Women
      • Lower leg 12.83
      • Cheek 10.91 %
      • Thigh 8.03 %
      • Foot 7.07 %
      • Knee 2.28 %
  • Mucosal melanomas (mucosal melanomas): preferentially occurring in the head and neck region (55%) in addition to the anorectal (24%) or genital region (21%); incidence peak in the 5th-8th decade of life; incidence (frequency of new cases): 0.04 cases per 100,000 population per year (USA).
  • Eye (conjunctiva (conjunctiva)/Uvea (medial eye skin).
  • Vulvar melanoma: After vulvar cancer (cancer of the vulva; cancer of the external genital organs of women), the second most common tumor of the vulva (< 1% of all malignant melanomas); amelanotic, i.e., nonpigmented, melanomas are also possible
  • Subungual melanomas: see explanations under “warning signs (red flags)” (1-2 % of all malignant melanomas).

Other forms of melanoma

  • Amelanotic melanoma: pigment-poor or pigment-free form of malignant melanoma observed mainly in people with skin type I; are rare, accounting for 2-8% of all malignant melanomas.
  • Lentigo-maligna melanoma: usually irregularly circumscribed, brown to brown-black, variably colored plaque (above the skin level elevating, “plate-like” substance proliferation of the skin); initially as lentigo maligna as a flat, brownish, patchy lesion; localization: Sun-exposed areas (face, but also the forearms and backs of the hands); long preinvasive lead time[dermoscopy (reflected light microscopy): invasive lentigo maligna melanoma shows irregular pigmentary nests and reticular breaks].

Warning signs (red flags)

  • Age:
    • Children: melanomas often present atypically in children, i.e., they do not show typical characteristics as in adults; typical misdiagnoses include benign nevus (benign pigmented mole), a wart, a pustule (“pustule”), or a vascular or acneiform lesion (vascular or acne-related “skin lesion”)
        • Relatively rapidly developing, symmetrical nodule; may be dark, but may also be pigment-poor to reddish; may have an erosive surface (resembling a granuloma pyogenicum) → think of: Melanoma
        • Skin lesions that have changed or bled in the past or are ulcerated (“ulcerated”) → think of: Melanoma
    • Old patients + pigmented lesions → think of: Melanoma; always a differential diagnostic clarification is required and in case of uncertainty a biopsy (tissue sampling) must be performed.
  • Suspicion of nail mycosis (nail fungus) with hemorrhage → think of: subungual melanoma ( “below a nail”).
  • Melanonychia striata longitudinalis (longitudinal melanonychia; longitudinal striate nail pigmentation); dermatoscopic features (→ think: subungual melanoma/nail melanoma):
    • Gray or black color
    • Irregular brown granular nail pigmentation with periungual pigmentation (Hutchinson’s sign I = highly suspicious) with or without nail dystrophy; DD subungual hemorrhage.
    • Spread over at least two-thirds of the nail.
    • Sudden appearance in previously inconspicuous nail plate
    • Suspicious especially on the thumb, index finger or big toe.
    • Additional signs of nail dystrophy
    • Age: usually > 60 years

    Note: Subungual melanomas are up to 25% amelanotic (pigment-poor or pigment-free form of malignant melanoma): amelanotic subungual melanomas. Clinical presentation:

    • Little painful, reddish growths with destroyed or detached nail plate.
    • Absence of the obligatory longitudinal striation of the nail plate.
  • Trauma, warts or calluses plantar (“in the area of the sole of the foot”) → think of: plantar melanomas.

In ungual and acral (“belonging to the extremities ends”) lesions always think of the 3 T:

  • Tinea (fungus)
  • Trauma (injury)
  • Tumor

Note: If within 1-2 months a lesion does not heal under therapy, a histological (fine tissue) examination is always required! Further notes

  • According to one study, patients with fewer than 20 nevi have tumors with a thickness of approximately 2.3 mm in contrast to the group of those with the most nevi with tumors of only 0.1 mm thickness on average.