Skin cancer or melanoma is the most aggressive tumor among other cancers. It develops from pigment cells of the skin. About 130,000 cases are diagnosed annually worldwide, which is 1% of all malignant neoplasms. Treatment in Germany melanoma is successful in 90% of cases, thanks to early diagnosis and timely treatment of the disease. In the early stages of the disease, the survival rate is 95%. Destruction of melanoma includes surgical methods, as well as radiation and chemotherapy.
Diagnosis of melanoma
Examination and interview
For prevention and early detection of the disease, you need to know the characteristics of your skin: the nature of moles, their size, shape, color, itching or bleeding. If their size, shape and color change, you should consult a doctor.
First, the specialist will conduct a thorough interview, identifying risk factors for cancer:
— ultraviolet radiation,
— cases of illness in other family members,
— a certain phenotype: blond hair, blue eyes, pink freckles,
— sunburns as a child,
— age 50 and older.
All the patient’s complaints and symptoms are divided into two types:
1) specific:
— change in the size, shape, color of the mole,
— itching at the site of the mole,
— bleeding from scratching.
2) general (neoplastic syndrome), occur in all cancers:
— weakness,
— fatigue,
— excessive sweating,
— weight loss.
Next, the doctor examines all moles and age spots on the patient’s body. The doctor is guided by the ABCDE rule. This is an abbreviation of the English words that characterize one of the features of a mole or nevus.
A (Asymmetry) — Asymmetry. One half of the mole is different from the other.
B (Borde)- the edges of the mole. The edges are irregular, blurred, serrated.
C (Color) — color. The color of moles can vary throughout the body. It is worth paying attention if they have changed color, there are areas of a different color (pink, black, red, white or blue) on one mole.
D (Diameter) — a spot diameter greater than 6 mm across requires a doctor’s examination.
E (Evolving) — progression, that is, an increase or change in size, shape, and color.
In addition to moles and nevi, the specialist palpates the lymph nodes. If they are enlarged, this may indicate the spread of a malignant process.
Instrumental methods of melanoma investigation
After the interview and examination, the physician performs dermatoscopy. It is a non-invasive method for early diagnosis of melanoma. German clinics use high-precision equipment Vision Derma Pro. The device provides an image magnified ten times and then fixes it, which makes it possible to monitor the pathological process in dynamics.
If the mole or birthmark looks malignant and the result of dermatoscopy confirms it, the dermatologist performs a biopsy. The operation is performed under local anesthesia, a piece of pathological tissue is isolated for histological and cytological analysis.
Several biopsy options are distinguished:
— «Razor» (tangential). The doctor cuts away the top layers of skin with a small surgical blade. Bleeding at the site of excision is stopped by applying an ointment or chemical, or by electrocoagulation. «Razor» biopsy is indicated for many types of skin conditions.
— Pincer. For it, the dermatologist uses an instrument that looks like a tiny, round, hand-held dough knife to dissect deeper skin samples. The skin sample is removed and the edges are stitched together.
— Incisional and excisional. With incisional — part of the focus is excised, with excision — the pathologic focus is removed completely.
— «Optical». Melanoma affects the retina of the eye in addition to the skin. Confocal microscopy is used to perform a retinal biopsy.
In some cases, the tumor spreads so rapidly that the primary focus (mole) has not yet had time to grow to the size needed for biopsy.
Along with the altered mole, the specialist examines the nearest lymph nodes
— A fine needle biopsy is used to diagnose lymph node abnormalities. The doctor uses a syringe with a thin, hollow needle to remove very small pieces of a lymph node or tumor. The needle is smaller than the needle used for blood tests. Sometimes local anesthesia is used. This test rarely causes much discomfort and does not leave a scar. If the nodule is large enough, the doctor performs the procedure without special instruments. If the node is deep enough, ultrasound or CT scanning can help locate the needle.
— A sentinel lymph node biopsy is necessary to diagnose the spread of melanoma. If pathology is found in a sentinel or sentinel lymph node, it is assumed that the cancer has spread to nearby lymph nodes. Therefore, removal of all sentinel lymph nodes is performed. To determine changes in the tissues, a contrast agent is injected into the tumor, which after some time spreads into the surrounding structures. If the color in any nearby lymph nodes changes, then the process is malignant. In this case, a surgical operation is performed: lymphodissection.
Melanoma laboratory testing
All samples of the obtained material are sent to the pathology department, where histologic and cytologic examination is performed. The samples are evaluated using:
— immunohistochemistry (IHC),
— Fluorescence in situ hybridization (FISH)
— comparative genomic hybridization (CGH).
The thickness of the mass as well as the rate of mitosis in the cells is evaluated to determine the stage. A genetic test is performed to determine if there is a mutation in the BRAF gene. German cancer centers have developed targeted treatment for melanoma in patients with this type of mutation.
In addition, a test known as DecisionDx-Melanoma is performed, which determines the expression of the gene responsible for the spread of the disease. The results of the test influence the therapy regimen.
Methods such as CT, PET, MRI, ultrasound are used to detect metastases, assess the effectiveness of treatment.
Blood tests are not informative for diagnosis. But, dermatologists determine the level of lactate dehydrogenase, high values of which indicate a poor response to treatment.
Stages of melanoma
There are several classifications of the stage. The main one is based on the characteristic of the spread of melanoma.
Stage 0 — the focus is in the epidermis but has not spread to other layers of the skin.
Stage 1
1A — melanoma thickness up to 1 mm, no evidence of ulceration, mitosis rate less than 1/mm2, no other sources.
1B — there is evidence of ulceration, mitosis rate is the same, no other sources.
Stage 2
2A — melanoma thickness up to 2 mm, ulcerated, no other sources.
2B — melanoma up to 4 mm thick, ulcerated, no other sources.
2C — more than 4 mm thick, ulcerated, no other sources.
Stage 3
3A — any thickness, spread of the process to 1-3 lymph nodes, nodes are not enlarged.
3B — any thickness, ulcerated, spread of the process to 1-3 lymph nodes, nodes are not enlarged
3C — same + enlarged lymph nodes
Stage 4 — spread of the process beyond the skin, to other organs and tissues.
Depending on the stage of the process depends on the treatment and prognosis of the disease.
Melanoma treatment in Germany
The treatment regimen will depend on factors such as the stage of the process, the patient’s condition, the presence of concomitant pathology, and the patient’s wishes.
Methods of melanoma therapy in Germany:
— surgical removal,
— immunotherapy,
— targeted therapy,
— chemotherapy,
— radiation therapy,
— palliative treatments.
In the early stages of the disease, the tumor is removed. In later stages, combined treatment is used. In addition to an oncologist, a radiologist, surgeon, and dermatologist are involved in the treatment process.
In advanced cancers, there are opportunities to participate in clinical trials new effective drugs. There is a special department in German clinics where they recruit and determine indications for participation in various clinical trials for the treatment of cancer. It is often this opportunity that gives a chance for recovery.
Surgical removal
Depending on the volume of the lesion, different methods of excision of the pathologic focus will be used.
Diagnostic surgery consists of removing the directly affected and a few millimeters of surrounding healthy tissue, after which the edges of the wound are stitched together. After such a procedure, a small scar remains. The dermatologist then uses a special microscope to look for the presence of cancer cells in the area of the suture. If the diagnosis is already established and the volume of melanoma is large enough, the doctor removes deeper layers of skin along with a small section of healthy tissue.
Another technique where the surgeon removes one layer of tissue, then uses a microscope to determine if there are malignant cells in the layer below. If there are, he removes it and looks at the next layer. And so on until no pathologically altered elements remain in the tissue.
Immunotherapy
Immunotherapy uses drugs to stimulate a person’s own immune system so that it can more effectively recognize and destroy cancer cells.
PD-1 inhibitors, Pembrolizumab (Keytruda) and nivolumab (Opdivo), are drugs that inhibit the work of PD-1 proteins. Blocking these proteins allows the immune system to work against the malignant tumor. Administration of the drug slightly reduces the size of the tumor, which increases life expectancy.
Viral therapy
A new trend in tumor removal is the use of oncolytic viruses. The structure of the virus is changed in the laboratory and then injected into patients. The viruses act on cancer cells. In addition to directly killing cells, viruses can also «teach» the immune system how to attack cancer cells. Talimogene laherparepvec (Imlygic), also known as T-VEC, is an oncolytic virus that can be used to kill melanoma in lymph nodes that cannot be removed by surgery.
Other methods
The Calmette-Guerin (BCG) vaccine is used to remove a stage 3 tumor. It is injected directly into the tumor. Imiquimod cream — Imiquimod (Zyclara) is an ointment or cream applied to melanoma skin. It activates an immune response directly in the skin, destroying cancer cells.
Cost of melanoma treatment in Germany
The price of melanoma treatment depends on many factors. Preliminary diagnosis of the disease is carried out, the stage of the process is determined. After that, the doctor determines the necessary scheme. The cost may change directly during treatment, as drugs may cause side effects, or the tumor may not respond to therapy.
Prices for melanoma treatment in Germany.
The second opinion is 140 Euros.
Diagnosis_______________ 850 — 1200 Euro, 5 days, outpatient
Vaccination
autologous
dendritic
cages acc-
ompanied by
chemotherapy_____________11000 Euro, 6 days, outpatient
(1 course)
Micrographic
surgery _________________3500 — 4150, 4 days, inpatient
Target
Therapy (1 course)_____________3650 — 4300, 6 days, inpatient
Radical,
extended
surgical
resection__________________6100 — 9000 Euro, 4 days, inpatient
«Second Opinion»-
counseling
leading specialist
based on the results
conducted survey
at the patient’s place of residence _____________ 140 Euro
How to choose the right clinic?
German clinics employ high-level professionals with state-of-the-art technology and equipment. German clinics are included in international ratings, where they take the leading place in terms of the quality of medical care. When applying to German clinics, a patient receives an individual approach, analysis of the situation by experienced specialists from various fields of medicine, high-quality treatment, as well as recommendations on further care.
Our expert doctors will help you to choose a clinic and a leading specialist for effective melanoma treatment in Germany. They know the real and current rating of every dermatologist and surgeon in Munich, as they have the opportunity to observe the results of their medical work on a daily basis.