Epidemiology of melanoma in Nikšić, Montenegro’s largest municipality Ana Popović 1,2 ✉ , Milica Đurović Bojić 1,2 , Miloš Bojić 3 , Tanja Pješčić 4 , Milena Ražnatović Đurović 1,2 1 Clinic of Dermatology and Venereology, Clinical Center of Montenegro, Podgorica, Montenegro. 2 Faculty of Medicine, University of Montenegro, Podgorica, Montenegro. 3 Department of Plastic Surgery, Clinical Center of Montenegro, Podgorica, Montenegro. 4 Primary Health Care Nikšić, Nikšić, Montenegro. 15 2025;34:15-18 doi: 10.15570/actaapa.2025.6 Introduction The rising incidence and associated mortality of melanoma have become a well-recognized public health concern (1). Despite ad- vances in technology, pharmaceuticals, and overall medical de- velopment, the severity of melanoma remains a significant chal- lenge due to its rapid progression when diagnosed late (2). The most effective way to combat this complex disease is through prevention or early detection. This is closely linked to the popu- lation’s medical knowledge, making public awareness a crucial responsibility of public health institutions (3). Tracking risk factors and developing new methods for early melanoma detection are of critical importance (4). Although cer- tain racial phenotypes contribute to an increased risk of skin can- cer, factors such as immunosuppression and a history of mela- noma pose an even greater risk (5). Identifying and monitoring precursor lesions, particularly atypical nevi, is essential for early intervention (6). Genetic mutations associated with an increased risk of melanoma include CDKN2A, CDK4, BAP1, TERT, MITF, MC1R, and POT1 (7). Ultraviolet (UV) radiation is the leading environmental fac- tor contributing to melanoma development, with meta-analyses highlighting the relative risks associated with various forms of UV exposure (8, 9). Although the 5-year survival rate for melanoma in Europe has been increasing, notable disparities remain, with survival rates surpassing 90% in Nordic and Western countries but being significantly lower in eastern Europe (10). Since the 1980s, early melanoma detection through naked-eye examination using the ABCDE criteria (asymmetry, border irregu- larity, color variability, diameter ≥ 6 mm, and evolution or recent change) has increased by 65% (11). However, this method remains imperfect and requires additional diagnostic techniques for more precise evaluation. Melanoma can affect individuals of all ages, with incidence rates rising among younger populations. Therefore, promoting preventive measures is essential, with dermoscopy playing a par- ticularly vital role in early melanoma detection (12–14). Dermos- copy units have proven highly effective in reducing unnecessary excisions of benign lesions in high-risk patients. Research sug- gests that dermoscopy is a cost-effective tool for melanoma detec- tion and should be routinely utilized by specialists as well as fam- ily physicians (15). Regular dermoscopic evaluations, along with routine skin checkups, should be a standard practice for both general physicians (GPs) and dermatologists to aid in the preven- tion and early detection of melanoma (16). Encouragingly, recent findings indicate an increasing trend in dermatologic checkups performed by GPs. A study by Fee et al. highlighted that—although both GPs that use dermoscopy and those that do not acknowledge its value in improving pri- mary care skin assessments—inadequate training in dermoscopic techniques remains a major barrier. This gap could be addressed through future educational campaigns (17). To the best of our knowledge, no similar study has been con- ducted in Montenegro. The aim of this study was to assess the oc- currence of melanoma following dermoscopic examinations, the reasons for patient visits, the presence of social inequalities, and the characteristics of confirmed melanomas, including their size and localization. Abstract Introduction: Melanoma can affect individuals of all ages, and its incidence is increasing among younger populations. Dermos- copy units are highly effective in reducing the number of benign lesions excised in high-risk patients. The aim of this study was to determine the occurrence of melanoma following dermoscopic examinations, the reasons for patient visits, the presence of social inequalities, and the characteristics of confirmed melanoma, including size and localization. Methods: We conducted a retrospective descriptive study of patients examined at the Dermoscopy Unit of the Department of Der- matology at Nikšić General Hospital in Nikšić, Montenegro, from 2017 to 2022 using manual dermoscopy examination. Results: The study comprised 125 patients (74 male and 51 female). The main reasons for dermoscopic examinations were a personal history of atypical nevi and the presence of more than 100 melanocytic nevi. The mean thickness of melanoma in patients younger than 45 years was 0.96 mm, in patients 46 to 65 years old it was 1.08 mm, and in patients over 66 it was 1.38 mm. A statistically sig- nificant difference in melanoma localization was observed between sexes: in male patients melanoma occurred significantly more often on the trunk, whereas in female patients it was more frequent on the lower legs. Conclusions: Dermoscopy enhances diagnostic accuracy for skin lesions, benefiting both dermatologists and primary care provid- ers. Effective melanoma prevention strategies include practicing sun protection, performing monthly self-examinations for new or changing moles and birthmarks, and attending regular medical checkups. Keywords: dermoscopy, melanoma, incidence, localization, epidemiology Acta Dermatovenerologica Alpina, Pannonica et Adriatica Acta Dermatovenerol APA Received: 23 December 2024 | Returned for modification: 17 January 2025 | Accepted: 16 February 2025 ✉ Corresponding author: dermatologyana@gmail.com 16 Acta Dermatovenerol APA | 2025;34:15-18 A. Popović et al. Methods This retrospective descriptive study was conducted among patients examined at the Dermoscopy Unit of the Department of Dermatology at Nikšić General Hospital in Nikšić, Montenegro, from 2017 to 2022. The study included patients that underwent dermoscopic examination and subsequently proceeded with a biopsy based on the findings. During dermoscopic evaluation, patients were positioned comfortably to allow optimal access to the area of interest. The skin was cleaned prior to examination to ensure accurate lesion visualization, with any interfering substances, such as creams or oils, removed. For specific anatomical locations, such as the scalp or nail bed, necessary adjustments were made, including parting the hair or ensuring clear views of the subungual region. A dermatoscope was used to examine skin lesions in either contact or non-contact mode. In contact dermoscopy, a transparent gel was applied to the skin surface to minimize light reflection and enhance visualization of subsurface structures, followed by direct placement of the dermatoscope onto the lesion. The variables analyzed for each patient included demographic data (sex, age, and Fitzpatrick skin phototype), reasons for referral (including multiple factors), and melanoma characteristics. Institutional board approval (no. 10683) was obtained from Nikšić General Hospital for this study. Statistical analysis was performed using IBM SPSS software version 26.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to assess the mean, standard deviation (SD), and range (minimum and maximum) of the variables. Categorical variables were expressed as frequencies and percentages. For comparisons, various statistical tests were applied, including ANOVA, the Wilcoxon signed-rank test, and Pearson’s correlation coefficient. A significance level of p < 0.05 was set for all analyses. Results An estimated 600 patients underwent dermoscopic examination at Nikšić General Hospital between 2017 and 2022. Of these, 125 patients with suspected lesions were referred to the Department of Surgery for biopsy. Histopathological evaluation confirmed pri- mary melanoma in 75 patients, and 10 patients with a previous diagnosis of primary melanoma were found to have developed a new primary melanoma. Our study included 74 male and 51 female patients. Their de- mographic characteristics, including distribution by sex, skin phototype, and age range, are presented in Table 1. The reasons for referral to the dermoscopy department were varied, as shown in Figure 1. The most common reasons included a personal history of atypical naevi (29.4%), the presence of more than 100 melanocytic naevi (27.1%), a family history of melanoma in a first-degree relative (14.8%), a personal history of melanoma (11.8%), and the presence of congenital melanocytic naevi (5.9%). The majority of patients (43.5%) independently noticed suspi- cious lesions and sought dermatologic evaluation, and 30.6% were referred by healthcare professionals, including general prac- titioners and specialists. Among patients with a negative histopathological evaluation for melanoma, none were immunosuppressed. However, in the group with confirmed melanoma, six patients were immunosup- pressed: two had undergone organ transplantation, one was HIV- positive, and three had a history of non-skin-related malignancies. Melanoma-confirmed lesions We analyzed 85 lesions confirmed as melanoma. The mean thickness of melanoma in patients under age 45 was 0.96 mm (SD = 0.48), in patients 46 to 65 years old it was 1.08 mm (SD = 0.95), and in patients over 66 it was 1.38 mm (SD = 1.11). The Table 1 | Demographic characteristics of patients in the study with data on patients during follow-up by sex, skin phototype, and age. Total Melanoma confirmed at follow-up p-value Yes No Sex, n (%) Male 74 (59.2) 45 (60.8) 29 (39.2) 0.03* Female 51 (40.8) 40 (78.4) 11 (21.6) Fitzpatrick type, n (%) II 79 (63.2) 57 (72.2) 22 (27.8) 0.14 III 46 (36.8) 28 (60.0) 18 (40.0) Age (years), n (%) 20–45 31 (24.8) 15 (48.4) 16 (51.6) 0.01* 46–65 51 (40.8) 35 (68.8) 16 (31.4) > 66 43 (34.4) 35 (81.4) 8 (18.6) *p < 0.05 is considered statistically significant. Figure 1 | a) Reasons for referral to the dermoscopy unit, categorized by three variables: suspicious lesion detected by the patient, a healthcare professional, or a family member. b) Reasons for referral to the dermoscopy unit, categorized by five additional variables. 17 Acta Dermatovenerol APA | 2025;34:15-18 Epidemiology of melanoma in Nikšić mean thickness of melanoma by age group and sex is presented in Tables 2 and 3. Localization of melanoma The chi-squared test of independence revealed a statistically sig- nificant difference in melanoma localization based on sex. Mela- noma was significantly more likely to occur on the trunk in male patients, whereas in female patients it was more commonly found on the lower legs. Figure 2 presents the data on sex disparities in melanoma localization. Discussion The diagnosis of pigmented skin lesions can be challenging, even for experienced professionals, due to the wide variability in clini- cal presentation. As a result, further investigations are often re- quired. These methods can be classified into invasive (biopsy) and non-invasive techniques. Dermoscopy, also known as epilumines- cence microscopy, is the most effective non-invasive technique for evaluating and distinguishing suspicious melanocytic lesions, atypical lesions, and melanomas (18). However, a definitive diag- nosis can only be confirmed through histopathology. The primary reasons individuals seek mole checks include changes in existing moles or the appearance of new pigmen- tation or growth on the skin. In addition, a personal history of melanoma or a positive family history are also common reasons for seeking checkups (19). Our results align with this because the most frequent reason for seeking evaluation was a skin lesion no- ticed by the patients themselves, followed by those identified by healthcare professionals. Regarding the reasons for referral to the dermoscopy unit, the most common reason was a personal history of atypical moles, which was somewhat unexpected. In contrast, García Piqueras et al. reported that the most common reason in their study was a per- sonal history of melanoma (16). In our series, a personal history of melanoma ranked fourth as a reason for referral. The second most common reason was the presence of a large number of nevi on the skin, which aligns with expectations because individuals with numerous moles are often more knowledgeable about pigmented skin lesions and are generally more proactive about preventive measures. In addition, some patients did not fall into any of the aforementioned categories and visited the dermoscopy unit either by chance or without a specific risk factor. Seventy-five percent of our participants were over 45 years old, with melanoma progression occurring more frequently in younger patients. This may be attributed to individuals with lower socio- economic status and those living in rural areas, who often have a reduced perception of melanoma risk, have limited knowledge about the disease and its prevention, and typically present with more advanced melanomas (20). Our study further reaffirms that age is a significant risk factor for developing melanoma because data show that the incidence of invasive melanoma increases with advancing age. However, it is important to note that the occur- rence of cutaneous melanoma is also rising rapidly among young adults, particularly women (21). This trend highlights the need for continued vigilance and monitoring of this high-risk group. No- tably, the municipality where this study was conducted primarily consists of an older population. Melanomas can develop anywhere on the body, although they are most commonly found in sun-exposed areas such as the face, back, and legs. However, a smaller proportion of melanomas can also arise in less exposed regions, including the feet, palms, and nail beds (22). The increasing incidence of melanoma in younger populations is largely attributed to more active, “careless” life- styles, with significantly higher exposure to ultraviolet radiation. Furthermore, individuals with occupational sun exposure, such as road workers, construction workers, and those in similar pro- fessions, are at an elevated risk (23). Regarding melanoma localization, our study aligns with estab- lished patterns. In men, melanomas are most frequently found on the back and other areas of the trunk (from the shoulders to the hips), as well as the head and neck. In women, the most common sites are the lower legs (24). Literature also suggests that the inci- dence of melanoma varies by sex, with higher rates in older males and younger females (25). In our study, melanoma was found to occur significantly more often in males. Furthermore, our findings indicate that, across all age groups, melanomas tend to be thicker in men than in women. This sug- gests that male patients may present with more advanced or ag- gressive tumors at the time of diagnosis. Most studies on this topic have been conducted in North America and Europe, limiting the generalizability of these findings to other regions (26). The economic burden of skin cancer has been rising in recent years, with melanoma contributing significantly to healthcare costs in Europe (27). Continued public health efforts to implement evidence-based sun-safety interventions will be essential in re- ducing both the incidence of skin cancer and the financial strain associated with its treatment (28). SD = standard deviation. Table 2 | Mean Breslow thickness by age, men. Age (years) Patients, n Thickness, mm SD Min. Max. Mean 20–45 4 0.3 2.0 1.07 0.69 46–65 15 0.3 4.0 1.54 1.20 > 66 26 0.3 4.0 1.63 1.26 Figure 2 | Presentation of melanoma localization by sex; x-axis = sex, y-axis = number of lesions. Table 3 | Table 3. Mean thickness by age, women. Age (years) Patients, n Thickness, mm SD Min. Max. Mean 20–45 10 0.5 2.0 0.91 0.41 46–65 18 0.3 2.0 0.71 0.42 > 66 12 0.6 1.0 0.81 0.18 SD = standard deviation. 18 Acta Dermatovenerol APA | 2025;34:15-18 A. Popović et al. Conclusions Referral to the dermoscopy unit in our study was most commonly due to a personal history of atypical moles or the patient’s own detection of suspicious lesions. This descriptive study highlights the ongoing need to improve awareness of early melanoma detec- tion and the importance of regular skin examinations. Despite ad- vances, significant efforts are still required to enhance prevention and education initiatives. 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