Subungual melanoma: management considerations

Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
American journal of surgery (Impact Factor: 2.36). 03/2008; 195(2):244-8. DOI: 10.1016/j.amjsurg.2007.03.010
Source: PubMed

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.

  • Piel 05/2014; DOI:10.1016/j.piel.2013.10.016
  • [Show abstract] [Hide abstract]
    ABSTRACT: Subungual melanoma (SUM) is rare and represents approximately 2–3% and 20% of all cutaneous melanomas in Caucasians and Asians, respectively. Amputation has usually been performed for invasive SUM; however, not all invasive SUMs invade or attach to the distal phalanx. To investigate the possibility of non-amputative surgery for patients with invasive SUM, the distances between the deepest base of the melanoma cells and the bony surface in the surgical specimens of invasive SUM were measured. Thirty surgical specimens of invasive SUM were retrospectively reviewed. The contents of the specimens were as follows: 14 first toes, 10 thumbs, three second fingers, two third fingers, and one fifth finger. Four specimens showed bone invasion, and the tumor was attached to the bone in four specimens. The tumor-to-bone distance exceeded 0.9 mm in all the specimens with thicknesses <4 mm. In the non-ulcerated SUMs (nine specimens), only one SUM specimen showed bone attachment. There was a higher likelihood of bone attachment or invasion when tumor thickness (TT) exceeded 4 mm (Pearson chi-square test, P = 0.009; Fisher exact test, P = 0.004; student t test, 0.033). Univariate and multivariate analysis also revealed that thick TT had a statistically significant affect (odds ratio 1.807 and 1.865, 95% CI 1.11–3.01 and 1.11–3.13, P = 0.023 and 0.018). Non-amputative surgery may be possible for SUM tumors that are of intermediate-thickness. However, there has been little evidence demonstrating survival with non-amputative surgery for invasive SUM. A large, randomized, prospective clinical study is required to address this issue.
    The Journal of Dermatology 10/2014; 41(10). DOI:10.1111/1346-8138.12622 · 2.35 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Subungual melanoma typically presents as a darkened longitudinal stripe under the nail plate; however, this disease is frequently misdiagnosed, which leads to a delay in proper diagnosis. Subsequently, subungual melanoma historically has a relatively poor prognosis compared with other cutaneous melanomas, with the 5-year survival rate ranging between 16 and 80 percent. Historically, these lesions were removed using aggressive amputation. To date, the National Cancer Institute does not have guidelines for the treatment of subungual melanoma.
    Plastic &amp Reconstructive Surgery 08/2014; 134(2):259-73. DOI:10.1097/PRS.0000000000000529 · 3.33 Impact Factor