Subungual melanoma: A single center series from Dresden

Subungual melanoma (SUM) is a rare subtype in Caucasians. Histologically, most tumors are of the acrolentiginous type (ALM). This is a retrospective analysis of the years 2002–2019 at a certified skin cancer center. We observed 12 SUM patients with a median age of 76 years, seven men and five women (0.6% of all melanomas). The delay of diagnosis reached from 30 years to several months. Hallux and thumb were the most affected localizations. The dominant histologic type was ALM. Clinical symptoms were nail plate destruction (90.9%), bleeding (50.0%), pigmentation of the nail plate (33.3%), and a positive Hutchinson sign (25.0%). All tumors were treated surgically with three‐dimensional margin control. In six patients, amputation was performed. Median relapse‐free survival and overall survival were (56 ± 73.5) months and (112.5 ± 135.1) months, respectively. SUM is rare among Caucasian patients. Nail plate pigmentation and Hutchinson sign were not frequent. Amelanotic ALM with nail plate destruction was the dominant presentation in our series. Dermoscopy is of limited value for amelanotic subungual tumors. Early biopsy of unusual or treatment resistant nail disorders is recommended.     

Melanoma and squamous cell carcinoma on different nails of the same hand

Nail dyschromia, including melanonychia and erythronychia, encompasses a wide range of possible diagnoses. While the majority of these lesions are benign, malignancies of the nail unit represent a sinister, and potentially life-threatening, cause of nail dyschromia. Unfamiliarity with tumors of the nail apparatus can lead to a delay in diagnosis. A case is presented of a patient with two separate and concurrent malignant neoplasms of the nail unit, on different nails on the same hand, each featuring an unusual clinical presentation: amelanotic melanoma presenting as longitudinal erythronychia and squamous cell carcinoma in situ presenting as longitudinal melanonychia. This presentation underscores the need for a low threshold for biopsy in the presence of nail dyschromia of uncertain etiology.     

Proximal nail plate destruction in subungual melanoma could be a possible predictor of invasiveness thicker than 1.25 mm

Various patterns of nail plate destruction are common features in subungual melanoma (SUM), but there has been no reports regarding their clinical significance according to the pattern of nail plate destruction in terms of tumor thickness. We tried to find a relationship between dermal invasion of SUM and proximal nail plate destruction (PNPD). Clinical information of patients with SUM was reviewed retrospectively from seven dermatology training hospitals in Korea. The PNPD was defined as a visible loss of full thickness of nail plate touching the eponychium at the most proximal part of it. We evaluated whether there are correlations between patients' age, sex, location of SUM, Breslow thickness (BT) and the presence of PNPD. Among 93 patients with SUM, 36 (38.7%) showed PNPD. Sex and BT showed significant correlations with the presence of PNPD in univariate analysis (P < 0.05). BT, age and sex showed significant correlations with the presence of PNPD in multivariate analysis (P < 0.05). Among them, BT showed the strongest correlation with the presence of PNPD (area under the curve, 0.722) and the cut‐off value was 1.25 mm. In conclusion, we suggest that PNPD in SUM could be a possible predictor of invasiveness of more than 1.25 mm BT.     

Predictor of Subungual Melanoma against Benign Longitudinal Melanonychia: A Retrospective Cohort Study from Korea

BackgroundLongitudinal melanonychia (LM) is a common clinical finding. Most cases of LM are benign, and a wait-and-see approach is preferred in the management of this condition. Nevertheless, it is important for clinicians to distinguish subungual melanoma (SUM) from other benign LMs.ObjectiveTo evaluate the demographic and clinicopathologic characteristics of LM in the Korean population and to identify the predictor of SUM against other benign conditions.MethodsThis was a single-center retrospective cohort study including patients who underwent nail biopsy for LM from January 2000 to May 2019. To identify the predictor of SUM, receiver operating characteristic (ROC) analyses was performed.ResultsA total of 68 cases of biopsy-proven LM were included in the analysis. Among the 68 cases, 8 were SUM. In univariable analysis, patients diagnosed with SUM were older (p=0.035) and had a longer disease duration (p=0.004). They also showed multicolor pigmentation of LM (p=0.022), a larger width of LM (p<0.001), and associated nail plate dystrophy (p=0.010) than patients diagnosed with benign conditions. In multivariable logistic regression, width of LM showed statistical significance (odds ratio, 1.083; 95% confidence interval, 1.018~1.153). ROC analysis suggested that an LM width >28% of the whole nail was the predictor of SUM (area under the curve=0.883; p<0.001).ConclusionSUM has distinct demographic and clinical features. The width of LM can predict SUM against other benign LMs.     

Amelanotic subungual malignant melanoma with multiple nodular local skin metastases

We present a 72-year-old man with a subungual amelanotic malignant melanoma (MM) on the right first toe with numerous local nodular metastases after trauma and without regional lymph node involvement. Most of the lesions were angiomatous (reddish blue), and some had a hyperkeratotic surface, clinically resembling Kaposi sarcoma. Results of biopsies performed on skin taken from the toe and from a metastatic lesion of the tibia revealed a classic case of amelanotic MM. This case has 2 interesting points: the clinical presentation of the metastatic lesions and the topical spreading of the lesions, which was initiated after traumatic injury of the prime lesion.     

Subungual amelanotic malignant melanoma

A 52-year-old man with subungual amelanotic malignant melanoma was reported. He had a dome-shaped tumor on his right thumb nail bed without any involvement. Clinically, we considered various diseases including amelanotic malignant melanoma, squamous cell carcinoma, granuloma pyogenicum, and other granulomas. Histological features of the skin biopsy taken during the first visit suggested squamous cell carcinoma. We still considered the possibility of amelanotic malignant melanoma, however, and the specimens taken during the radical operation were examined histologically and histochemically and a diagnosis of subungual amelanotic malignant melanoma was determined.     

Bowen disease of the nail apparatus. Report of 5 cases and review of the 20 cases of the literature (author's transl)]

Five cases of Bowen disease of the nail apparatus were studied and the 20 cases published to date reviewed. The lesion was characterized by either periungual redness with scaling and erosions, whitish cuticle, hyperkeratotic or papilomatous process, fissure or crusted ulcer in the lateral nail fold or the nail bed with eventual partial or total destruction of the nail plate and sometimes soreness on the pressure. The key of the diagnosis is the histological picture, identical with that of Bowen diseases of other skin areas. Among the 25 cases, Bowen disease was found mainly in males (20 out of 25 patients) on the left fingers (17 out of 25 finger lesions) with particular involvement of the 1st, 2nd, 3rd finger nail. Hallux was concerned twice. The clinical picture can be protean and mimic verrucae, onychomycosis, paronychia, eczema, pyogenic granuloma, verrucous tuberculosis, subungual exostosis, glomus tumor, dermatitis vegetans, amelanotic malignant melanoma, kerato-acanthoma and of course squamous cell carcinoma. Treatment of choice is complete removal of the tumor by plastic surgery otherwise microscopically controlled excision following chemical fixation (Mohs) or fresh tissue technique.     

Conservative surgical management of subungual (matrix derived) melanoma: report of seven cases and literature review

Background Subungual melanoma (SUM) is a rare entity, comprising approximately 0·7–3·5% of all melanoma subtypes. SUM histopathologically belongs to the acral lentiginous pathological subtype of malignant melanoma. Its diagnosis is helped by dermoscopy but pathological examination of doubtful cases is required. Classical management of SUM is based on radical surgery, namely distal phalanx amputation. Conservative treatment with nonamputative wide excision of the nail unit followed by a skin graft has been insufficiently reported in the medical literature even though it is performed in many centres. Objectives To report a series of patients with in situ or minimally invasive SUM treated by conservative surgery, to investigate the postoperative evolution and to evaluate the outcome with a review of the literature. Methods We performed a retrospective extraction study from our melanoma register of all patients with in situ and minimally invasive SUM treated with conservative surgery in the University Hospital Department of Dermatology, Lyon, France from 2004 to 2009. The patient demographics, disease presentation, delay to diagnosis, histopathology and postoperative evolution were reviewed. Results Seven cases of SUM treated as such were identified in our melanoma database. All cases had a clinical presentation of melanonychia striata. The mean delay to diagnosis was 2 years. Surgical excision of the entire nail unit with a 5–10 mm safety margin without bone resection followed by full‐thickness skin graft taken from the arm was performed in all cases. No recurrence was observed with a mean follow‐up of 45 months. Functional results were found satisfactory by all patients and their referring physicians. Sixty‐two other cases have been found in the literature and are also discussed. Conclusions Conservative surgical management in patients with in situ or minimally invasive SUM is a procedure with good cosmetic and functional outcome and, in our cases as well as in the literature, the prognosis is not changed.     

Delayed Reconstruction for the Non-Amputative Treatment of Subungual Melanoma

Background

In cases of early stage subungual melanoma (SUM), conservative treatment with non-amputative wide excision of the nail unit and subsequent skin graft is preferred over amputation to preserve the involved digit.

Objective

We report a series of patients with SUM treated with conservative surgery and suggest an effective supplementary treatment process.

Methods

We retrospectively reviewed 10 patients (2 males, 8 females) who were diagnosed with in situ or minimally invasive SUM on the first biopsy and underwent non-amputative wide excision of the nail unit. All patients underwent secondary intention healing during the histopathological re-evaluation of the entire excised lesion, and additional treatment was administered according to the final report.

Results

In two of 10 patients, amputation was performed because of the detection of deep invasion (Breslow thickness: 4.0, 2.3 mm) from the final pathologic results, which differed from the initial biopsy. In six patients who received delayed skin graft, the mean total time required for complete healing after secondary intention healing and the skin graft was 66.83±15.09 days. As a result of this delayed skin graft, the final scarring was similar to the original shape of the nail unit, scored between 5 and 10 on a visual analogue scale. Most patients were satisfied with this conservative surgery except one patient, who had volar portion involvement and received an interpolated flap instead of a skin graft.

Conclusion

Our treatment process can reduce the risk of incomplete resection and improve cosmetic outcomes in patients with SUM.     

Dermoscopic features of acral lentiginous melanoma in a large series of 110 cases in a white population

Summary Background Acral lentiginous melanoma (ALM) is a rare but distinctive subtype of melanoma. The diagnosis is often delayed and misdiagnosis is common, due to frequently unusual clinical presentation and a higher rate of amelanosis than in other melanoma subtypes. Objectives We aimed to investigate the dermoscopic features of a large series of ALM in a white‐skinned population, in order to emphasize their diagnostic value. Methods All recorded dermoscopic photographs of ALM, including nail unit variants, were collected from the files of the University Hospital Department of Dermatology (Lyons, France) and reviewed. Results In total 110 lesions, including 66 (60%) palmoplantar ALM and 44 (40%) ALM of the nail apparatus, were analysed for dermoscopic characteristics. The mean Breslow thickness was 2·6 mm. In volar skin melanomas, the two most prevalent patterns were irregular diffuse pigmentation (60%) and the parallel‐ridge pattern (53%). Minor dermoscopic patterns, commonly noted in benign lesions, were also detected but only focally within the lesions. Among the 44 nail unit lesions, 31 (70%) presented irregular lines with variegations in colours, spacing, width and disruption of parallelism. Two cases of melanonychia striata had a triangular shape. Both corresponded to early ungual ALM. Association with subungual haemorrhage was not uncommon. The study included 37 (34%) amelanotic melanomas. However, dermoscopy enabled detection of microscopic remnants of pigmentation in most cases. The vascular pattern found in almost half of these lesions was polymorphous, with combinations of milky‐red areas (95%), linear irregular vessels (49%), dotted vessels (43%) and hairpin vessels (41%). Conclusions The presence of a parallel‐ridge pattern and/or irregular diffuse pigmentation within the lesion is highly indicative of melanoma on volar skin. An irregular lines pattern is the most prominent dermoscopic feature of pigmented ALM of the nail apparatus. Amelanotic ALM either in volar skin or in nail apparatus is characterized by remnants of pigmentation and a polymorphic vascular pattern.     

Cirugía funcional en tumores malignos subungueales. Serie de casos y revisión de la literatura

Background and objectives

Amputation is the conventional treatment for malignant subungual tumors (MSUTs), namely, subungual squamous cell carcinoma (SUSCC) and subungual melanoma (SUM). Functional surgery consisting of wide local excision (WLE) of the nail unit can preserve function without modifying prognosis in such cases. We present a series of MSUTs treated with WLE of the nail unit, describe the technique, and review its indications.

Effects of non‐amputative wide local excision on the local control and prognosis of in situ and invasive subungual melanoma

Subungual melanomas (SUM) are rare, and amputation is often required. Non‐amputative wide local excision (WLE) of the nail unit with the periosteum of the distal phalanx, followed by skin graft, has been accepted for in situ or SUM of 0.5 mm or less thickness. However, previous reports have included a limited number of cases, and not all more than 0.5‐mm thick SUM exhibit invasion or attachment to the distal phalanx. The aim of the present study was to investigate the local recurrence and prognosis for in situ, minimally invasive and invasive SUM that were treated using WLE. We retrospectively reviewed 50 patients with in situ (n = 48) or minimally invasive SUM (n = 2) (in situ or minimally invasive group) and 12 patients with more than 0.5‐mm thick invasive SUM (invasive group) who were treated using WLE. All patients survived the follow‐up period (24–207 months), although four patients with in situ SUM experienced local recurrence at the lateral margin and re‐excision was required. In the invasive group, no patients experienced local recurrence, although one patient (8.3%) developed nodal metastasis at 86 months and regional lymph node dissection was required. WLE may provide acceptable local control for in situ and intermediate thickness SUM, without compromising the vital prognosis. However, a larger randomized prospective study with long‐term follow up is required to evaluate adequately the risks associated with a non‐amputative WLE for in situ and invasive SUM.     

Clinical and dermoscopic characteristics of amelanotic melanomas that are not of the nodular subtype

Background Amelanotic melanomas remain challenging to diagnose. Objective To analyze and describe the clinical and dermoscopic characteristics of amelanotic melanomas that are not of the nodular subtype. Patients/Methods We conducted a retrospective review of 20 consecutively diagnosed amelanotic melanomas. The clinical and dermoscopic images of pathologically confirmed amelanotic melanomas that were not of the nodular subtype were analyzed. In addition, the clinical diagnosis and the reasons why these lesions were biopsied were examined. Results All 20 amelanotic melanomas were erythematous and lacked any of the clinical ABCD features commonly attributed to melanoma. The lesions appeared clinically to be relatively symmetric with regular borders and manifesting a circular to oval morphology. Dermoscopically, all lesions manifested polymorphous vascular pattern. Conclusions Amelanotic melanomas that are not of the nodular subtype often present as clinically symmetric erythematous lesions. Therefore, it is important to consider AMs in the differential diagnosis of isolated and persistent erythematous outlier lesions, even if they are symmetric in appearance. Additionally, the presence of a polymorphous vascular pattern seen with dermoscopy can facilitate in correctly identifying these melanomas.     

SUBUNGUAL EPIDERMOID INCLUSIONS

SUMMARY.— This paper describes the evolution of subungual epidermoid inclusions and discusses their aetiology. They are shown to develop from the tips of the rete ridges by a process of bulbous proliferation. Ultimately they may lose their connection with the epidermis and come to lie deeply within the dermis of the nail bed. Although the lesions are usually microscopic in size they may be large and should be considered in the differential diagnosis of nail bed swellings.
The aetiology of these lesions is still obscure. They may follow trauma and are found in finger clubbing and it is probable that different stimuli can produce them.     

Maligne Tumoren des Nagelorgans

Because of the large number of different tissues making up the distal phalanx of fingers and toes, a large variety of malignant tumors can be found in and around the nail apparatus. Bowen disease is probably the most frequent nail malignancy. It is usually seen as a verrucous plaque of the nail fold and nail bed in persons above the age of 40 years. It slowly grows over a period of years or even decades before degenerating to an invasive squamous cell carcinoma. The latter may also occur primarily often as a weeping onycholysis. The next most frequent nail malignancy is ungual melanoma. Those arising from the matrix are usually pigmented and often start with a longitudinal melanonychia whereas those originating from the nail bed remain amelanotic, are often nodular and mistaken for an ingrown nail in an elderly person. The treatment of choice for in situ and early invasive subungual melanomas is generous extirpation of the nail apparatus whereas distal amputation is only indicated for advanced melanomas. In addition to these frequent nail malignancies, nail-specific carcinomas, malignant vascular and osseous tumors, other sarcomas, nail involvement in malignant systemic disorders and metastases may occur. In most cases, they cannot be diagnosed accurately on clinical grounds. Therefore, a high degree of suspicion is necessary in all isolated or single-digit proliferations that do not respond to conservative treatment.     

Acquired periungual fibrokeratoma: a case report

Acquired periungual fibrokeratoma (APF) is an uncommon lesion located around the nail and related to acquired digital fibrokeratoma. Histologic features of APF include a core of thick collagen bundles oriented along the longitudinal axis of the tumor and a very characteristic pseudo-nail plate formation. Different terms have been used to describe these lesions, and there has been no consensus on the terminology for some years. It is now believed that trauma may play a role in the pathogenesis of these periungual lesions.     

Trichophyton Tonsurans Induced Recurrent Onychomadesis in a Very Young Infant

Abstract: Onychomadesis, or nail shedding, is rarely seen in children and can be due to stress, systemic illnesses, trauma, and drug therapy or may be idiopathic. Fungal infection of the nail is only rarely reported as a cause of onychomadesis. We present here a case of Trichophyton tonsurans–induced onychomycosis and resultant onychomadesis in a 9‐month‐old boy with onset of lesions at 2 weeks of life.     

Secondary longitudinal melanonychia secondary to onychophagia

BACKGROUND: Melanonychia of the toenails sometimes results from repeated trauma. This etiology is rarely put forward in lesions affecting the fingernails. CASE REPORT: A 44-year-old woman developed melanonychia affecting 9 fingernails. Genetic predisposition and drug, hormonal or infectious causes were ruled out and we postulated that the lesions were induced by nail biting. DISCUSSION: Nail biting is known to lead to several types of lesions, including melanonychia. The lesions may sometimes disappear several months after stopping this habit.     

Detection of clinically amelanotic malignant melanoma and assessment of its margins by in vivo confocal scanning laser microscopy.

BACKGROUND: Near-infrared confocal scanning laser microscopy (CSLM) represents a novel imaging technique for in vivo microscopic analysis of skin lesions, including pigmented lesions. OBJECTIVES: To investigate the feasibility of detecting a clinically amelanotic malignant cutaneous melanoma using CSLM and to explore the use of this technique for assessing its margins. PATIENTS AND METHODS: Two lesions from 2 patients were imaged and analyzed using CSLM. Sites suspected to represent melanoma or benign skin on CSLM were marked as such; then, biopsy specimens were obtained for diagnosis using conventional histological analysis. Both lesions were stained for melanin pigment and analyzed immunohistochemically for the expression of melanosomal markers. In 1 case, a biopsy specimen was also examined with electron microscopy. RESULTS: The images obtained using CSLM allowed recognition of an abnormal intraepidermal melanocytic proliferation that was distinctly different from normal skin. Comparison of the sites examined using CSLM and subsequently using conventional histological methods revealed that CSLM correctly identified intraepidermal melanoma and benign skin. Fontana-Masson stains and immunohistochemical and ultrastructural studies showed that clinically amelanotic melanoma cells contained melanosomes and rare melanin granules. CONCLUSIONS: We demonstrated, for the first time, the detection of clinically amelanotic melanoma using CSLM. This technique may aid in the early detection of clinically barely visible or nonpigmented melanomas and may facilitate preoperative noninvasive assessment of their margins.     

Amelanotic lentigo maligna melanoma: a unique case and review of the literature

It has been estimated that 2 percent of all melanomas are clinically amelanotic, with amelanotic lentigo maligna melanoma being an even rarer presentation. These neoplasms have presented clinically as neurodermatitis, eczema, and erythema. Given the lack of clinical markers and subsequent delay in diagnosis of these lesions, they are potentially more dangerous than pigmented lentigo maligna melanomas. We report a case of an amelanotic lentigo maligna melanoma presenting as an ill-defined edematous area on the left cheek of an elderly woman.