Subungual melanoma: management considerations
ABSTRACT Patients with subungual melanoma (SM) often experience delayed diagnosis and present with deep primary lesions. Breslow depth of the primary lesion is often unknown before definitive resection, thus complicating treatment planning.
Patients with SM treated at our institution from 1992 to 2004 were identified from our prospective melanoma database. Clinical and pathologic factors were reviewed; Student t test and Kaplan-Meier method were used for statistical analysis.
Forty-nine patients were identified; most were female (63%). The median age was 66 years (range 24 to 83). The most common site was the great toe (n = 21), followed by the thumb (n = 15). Eight patients had in situ disease; 6 were treated initially with wide local excision, and 4 of these eventually required amputation. The median Breslow depth of invasive lesions was 2.1 mm (range .2 to 11). Toe lesions were thicker than finger lesions (mean 3.5 vs 2.5 mm, P = .005). Patients with invasive SM of the toe had a less favorable outcome than those with finger lesions (5-year overall survival 40% vs 72%, respectively; P = .05). Sentinel lymph node (SLN) biopsy was performed in 30 patients and was positive in 5 (17%); all underwent completion lymphadenectomy. Median Breslow depth in patients with positive SLN was 4 mm (range 1.2 to 11). Four of 5 patients with positive SLN developed recurrence (median 16 months); 3 patients died of disease within 40 months.
Patients with SM present distinct therapeutic challenges. They continue to present with deep primary melanoma, particularly on the toe. Undertreatment of early disease is associated with local recurrence.
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- "Early diagnosis of nail apparatus melanoma remains a challenge, even among experienced dermatologists [1, 11]. The ABCDEF  rule is intended to facilitate the clinical detection of subungual melanoma, but it has limitations. "
ABSTRACT: Longitudinal melanonychia can be caused by melanocyte activation (hypermelanosis) or proliferation (lentigo, nevus or melanoma). Histopathologic examination is mandatory for suspicious cases of melanomas. Tangential biopsy of the matrix is an elegant technique avoiding nail plate dystrophy, but it was unknown whether the depth of the sample obtained by this method is adequate for histopathologic diagnosis. Twenty-two patients with longitudinal melanonychia striata were submitted to tangential matrix biopsies described by Haneke. The tissue was stained with hematoxylin-eosin and the specimens were measured at 3 distinct points according to the total thickness: largest (A), intermediate (B) and narrowest (C) then divided into 4 groups according to the histopathologic diagnosis (G1: hypermelanosis; G2: lentigos; G3: nevus; G4: melanoma). The lesions were measured using the same method. The mean specimen/lesion thickness measure values for each group was: G1: 0,59/0,10 mm, G2: 0,67/0,08 mm, G3: 0,52/0,05 mm, G4: 0,58/0,10 mm. The general average thickness for all the specimens/lesions was 0,59/0,08 mm. We concluded that the tangential excision, for longitudinal melanonychia, provides an adequate material for histopathological diagnosis.Dermatology Research and Practice 03/2012; 2012:353864. DOI:10.1155/2012/353864
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ABSTRACT: Subungual melanoma is an uncommon form of acral melanoma that arises within the nail bed. The incidence for acral melanomas is similar worldwide, but the proportion is higher in dark-skinned individuals. The subungual form represents about 2% of cutaneous non-sun induced melanomas in the western world, and up to 75% in Africans, 10% in Japanese, and 25% in the Chinese of Hong Kong. Up to 33% of subungual melanomas are amelanotic. Black pigmentation of the adjacent nail fold, termed Hutchinson's sign, may be a diagnostic clue. Non-specific features and symptoms along with a high incidence of amelanosis often lead to delayed diagnosis, disease progression, and a poor prognosis with challenging treatment options.Acta dermatovenerologica Croatica: ADC / Hrvatsko dermatolosko drustvo 02/2008; 16(4):236-42. · 0.58 Impact Factor
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ABSTRACT: Subungual squamous cell carcinoma (SCC) is a rare malignancy with very few reported cases that occur on the toe. The etiology of these lesions is not known, and although this location is generally considered low risk for metastasis, cases of inguinal lymph node metastasis after toe amputation have been reported. Patients with subungual disease may meet criteria other than location that increase their risk for metastasis. Currently, no standardized approach to therapy for these patients has been established. In this article, we describe a patient with SCC of the right fourth toe with no clinical evidence of lymph-node metastasis. This patient underwent toe amputation and has done well for 2.5 years with no evidence of recurrence. We discuss this case of subungual SCC of the toe along with others in the literature to propose an optimal standardized approach for therapy and follow-up. In so doing, we aim to advance medical knowledge of subungual SCC and to improve patient care.Journal of Surgical Education 07/2008; 65(4):297-301. DOI:10.1016/j.jsurg.2008.05.013 · 1.39 Impact Factor