"Functional" Surgery in Subungual Melanoma

Department of Dermatology, University of Tuebingen, Tuebingen, Germany.
Dermatologic Surgery (Impact Factor: 2.11). 05/2003; 29(4):366-74. DOI: 10.1046/j.1524-4725.2003.29087.x
Source: PubMed


Subungual melanomas represent approximately 2% to 3% of cutaneous melanomas in White populations. Complete or partial amputation proximal to the distal interphalangeal joint of the digits has been suggested. Recently, we introduced for acral melanomas, similar to lentigo maligna melanoma, limited excision and complete histology of excisional margins (three-dimensional histology).
To evaluate the prognostic relevance of clinical parameters and different surgical management in patients with subungual melanoma.
From 1980 to 1999, subungual melanoma was diagnosed in 62 of 3,960 stage I and II melanoma patients (1.6%) of the melanoma registry of the Department of Dermatology (University of Tuebingen). A retrospective comparative analysis of two treatment groups was performed: Thirty-one patients had an amputation in or proximal to the distal interphalangeal joint (median follow-up of 55 months), and 31 patients had "functional" surgery with local excision of the tumor and only partial resection of the distal phalanx (median follow-up of 54 months).
In the univariate analysis, the level of invasion (P=0.0059), ulceration (P=0.0024), and tumor thickness (P=0.0004) were significant prognostic factors for recurrence-free survival but not for survival. In a multivariate analysis, only lower tumor thickness and a reduced level of amputation were independent significant prognostic parameters for recurrence-free survival (P=0.035 and P=0.0069). Patients with an amputation in or proximal to the distal interphalangeal joint did not fare better than patients with less radical "functional" surgery.
Limited excision with partial resection of the distal phalanx only and three-dimensional histology to assure tumor-free resection margins give better cosmetic and functional results and do not negatively affect the prognosis of patients with subungual melanoma.

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    • "In the past, the mainstream treatment was radical excision, including ray amputation regardless of the extent or stage of cancer. Recently, in cases of noninvasive or low grade skin cancer, proper excision of the skin cancer and suitable reconstruction of the soft tissue defect has been preferred due to regard for functional and aesthetical preservation [2]. "
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    ABSTRACT: Primary malignant tumors of the hand, although unusual, may present varied and often complex clinical problems. The main treatment modality of skin cancer of the hand has changed. We retrospectively reviewed the medical records of 43 patients who underwent surgery for malignant skin tumors of the hand during an 18-year period, from September 1994 to February 2012. The characteristics of the tumor, methods of reconstruction, and long-term results were reviewed. We had 43 patients with 27 melanomas, 14 squamous cell carcinomas, and 2 sarcomas. Their ages ranged from 19 to 74 years (mean, 53.4±14.5 years), from 46 to 79 years (mean, 59.7±9.6 years), and from 15 to 43 years (mean, 29±19.8 years), respectively. Thirty-four cases occurred on the fingertip (16 of those cases on the thumb), 5 cases occurred on the palm, and 4 cases on the dorsum of the hand. Amputation was most frequently used in early cases, but recently, tissue-sparing excision has been performed frequently. The incidence of local recurrence was 3 cases and distant metastasis was 1 case, and the 5-year survival rate was 100%, except in 4 cases due to follow-up loss. The principles of treatment-to be curative and to preserve function and appearance-are important points. "Preservative surgery" preserves function and cosmesis of the involved finger or hand dorsum or palm. Preservative surgery not only emphasizes less resection and surgery of a smaller scale, but also optimal reconstruction of the soft tissue defect of the digit.
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    • "Therefore, moderate amputations were proposed to preserve the extremities as long as possible without compromising safety margins.36 Moehrle, et al.38 reported a recent experience with "functional" surgery, avoiding amputation, and found a similar incidence of local recurrence and improved survival in the group of patients undergoing limited excision compared with patients undergoing amputation. Our study results also showed that the group treated by amputation did not have a statistically significant survival benefit than the group treated by local wide excision on melanomas of hands and feet. "
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    ABSTRACT: A retrospective study was conducted to review the treatment and outcomes of mainly melanomas in acral location in a single institution in Korea, and to evaluate the prognostic significance of anatomic locations of the tumor. A retrospective review was completed on 40 patients between 2001 and 2006 to obtain pertinent demographic data, tumor data, treatment characteristics, and follow-up data. Forty melanoma patients were identified and analyzed. Of these, 18 were male and 22 were female patients and the mean age at the time of diagnosis was 55.9 years. Of the tumors, 65% were located on the hands and feet with acral lentiginous melanoma being the most common histological subtype. Univariate analysis for the overall melanoma survival revealed that the thickness of the tumor and the clinical stage have prognostic significances. The most significant factor as analyzed by a multivariate analysis was shown to be the advanced clinical stage. Acral melanomas did not show statistically significant differences in the age at diagnosis, thickness of the tumor, stage, ulceration, and survival rates compared to non-acral melanomas. There was also no significant difference in the survival rate between the patients treated by amputation versus wide local excision in acral melanomas. In Korean melanoma patients, thickness and advanced stages are significant factors for poorer prognosis. However, the location of melanoma did not have a significant prognostic value. In treating the melanomas in acral location, local wide excisions resulted in a similar prognosis compared to amputations.
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