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Characteristics and Treatment for Nail Melanoma In Situ
TAKE-HOME MESSAGE
- A total of 6 cases of nail unit melanoma (NUM) in situ were treated with surgical excision of the whole nail unit. The area excised included the lateral and proximal nail folds and the distal pulp of the finger/toe with an extra margin of 6 mm down to the bone of the terminal phalanx, including the periosteum. The defect was closed with a full-thickness skin graft or left to heal by secondary intention. Patients were followed for 4 to 62 months.
- It is important to have a high index of suspicion and to diagnose NUM early. Wide excision with phalanx amputation has not demonstrated an improved disease-free survival in early cases of NUM. When Mohs surgery for NUM in situ is not available, excision of the nail with full-thickness skin grafting as described in this paper provides a good cosmetic and functional outcome.
– Sarah Churton, MD
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Nail unit melanoma (NUM) is a variant of acral lentiginous melanoma. The differential diagnosis is wide but an acquired brown streak in the nail of a fair-skinned adult person must be considered a potential melanoma. Dermoscopy helps clinicians to more accurately decide if a nail apparatus biopsy is necessary.
OBJECTIVE
Detailed evaluation of clinical and dermoscopy features and description of conservative surgery of in situ NUM.
METHODS
Retrospective study of in situ NUM diagnosed and treated with conservative surgical management in the authors' center from 2008 to 2013.
RESULTS
Six cases of NUM were identified: 2 male and 4 female patients, age range at diagnosis of 44 to 76 years. All patients underwent complete nail unit removal with at least 6-mm security margins around the anatomic boundaries of the nail. The follow-up varies from 4 to 62 months.
CONCLUSION
Nail unit melanomas pose a difficult diagnostic and therapeutic challenge. Wide excision is sufficient, whereas phalanx amputation is unnecessary and associated with significant morbidity for patients with in situ or early invasive melanoma. Full-thickness skin grafting or second-intention healing after total nail unit excision is a simple procedure providing a good functional and cosmetic outcome.
Additional Info
Nail Melanoma In Situ: Clinical, Dermoscopic, Pathologic Clues, and Steps for Minimally Invasive Treatment
Dermatol Surg 2014 Dec 17;[EPub Ahead of Print], AF Duarte, O Correia, AM Barros, F Ventura, E HanekeFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The following images were provided by the authors for PracticeUpdate users.
Figure 1: A linear black streak without evidence of Hutchinson’s sign was noted on the left great toe. The acute appearance of this led to dermoscopy for further assessment.
Figure 2: Dermoscopy from the proximal nail bed adjacent to the nail fold demonstrating brown bands irregular in color, width and spacing.
Figure 3: Dermoscopy from the distal nail bed demonstrates pigment along the full thickness of the free edge of the nail plate.
Figure 4: The nail bed biopsy demonstrates atrophy and a few atypical melanocytes which are difficult to distinguish from keratinocytes (H&E, x 200).
Figure 5: A few atypical melanocytes are noted at and just above the dermal epidermal junction. A nest of atypical melanocytes is noted in the dermis (S-100, x 400).
Figure 6: Collage of surgical images.