"Functional" surgery in subungual melanoma.
ABSTRACT 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.
- SourceAvailable from: Roberto GlorioArchivos argentinos de dermatología 01/2006; 56:191-194.
- [Show abstract] [Hide abstract]
ABSTRACT: Subungual melanoma is a rare subtype of melanoma that usually originates and spreads from the nail matrix. Because of its poor prognosis and short matrix-to-bone distance, amputation has been traditionally performed. Recently, conservative surgery has been attempted for early subungual melanoma, but the evidence supporting this practice is sparse. As little is known about the progression pattern of subungual melanoma, further advances on the subject may provide better guidance on the optimal surgical approach. Histopathology slides, clinical records, and photographs of 23 cases of subungual melanoma were reviewed. For all cases, each area of the nail unit-proximal nail fold, nail matrix, nail bed, and/or hyponychium-in longitudinal sections was available for histological examination. Growth pattern, dermal invasion, and thickness were assessed in each area of the nail unit. There were five cases of melanoma in situ. Eighteen cases showed dermal invasion in at least one area of the nail unit. There were no cases showing dermal invasion in the nail matrix area only. In four cases, dermal invasion involved areas of the nail unit other than the nail matrix. In 14 cases, dermal invasion involved the nail matrix area as well as other areas of the nail unit. Except for one case, the nail matrix area showed thinner dermal invasion compared with dermal invasion in other areas of the nail unit. In conclusion, dermal invasion of subungual melanoma in the nail matrix area tends to occur later than other areas of the nail unit. Longitudinal incisional biopsy is necessary to accurately evaluate melanoma invasion. The findings of this study suggest that conservative surgical treatment for early subungual melanoma may be justified as the nail matrix area, an area of thin dermis and close proximity to the underlying bone, appears to be more resistant to invasion.Modern Pathology advance online publication, 18 April 2014; doi:10.1038/modpathol.2014.65.Modern Pathology 04/2014; · 6.36 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Background Surgical treatment of acral lentiginous melanomas with wide excisional margins as recommended often requires amputation of distal extremities. The current study analyzes whether smaller excisions in combination with a complete histological evaluation of the excisional margins (3D histology) have a negative impact on the prognosis.Patients and methods304 patients were retrospectively evaluated. 192 patients with reduced excisional margins followed by 3D histology (group A) were compared with 112 patients treated with conventional wide margins (group B). The outcome of both groups was compared.ResultsThe median tumor thickness was higher in group A (p = 0.022) and ulcerations occured more frequently (p = 0.017). The median excisional margin was 8 mm in group A and 20 mm in group B (p < 0.0001). 10.9 % (4.2 % invasive) of group A und 8.9 % (4.5 % invasive) of group B (p = 0.577) developed a local recurrence in a median of 40 months. The melanoma specific 10-year survival was 66.8 % in group A und 63.4 % in group B (p = 0.531). There was no difference in survival of patients with or without local recurrence (p = 0.643).Conclusions Excision with small margins followed by 3D histology is not inferior to conventional surgery with wide margins in terms of the rate of local and has no negative impact on prognosis or the further course of the disease. Local recurrences are rare and do not influence patient survival.Journal der Deutschen Dermatologischen Gesellschaft 10/2014; 12(10). · 1.40 Impact Factor