Early features of subungual melanoma

NewsBot · Feb 2, 2008

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Subungual melanoma: a study of 124 cases highlighting features of early lesions, potential pitfalls in diagnosis, and guidelines for histologic reporting.
Tan KB, Moncrieff M, Thompson JF, McCarthy SW, Shaw HM, Quinn MJ, Li LX, Crotty KA, Stretch JR, Scolyer RA.
Am J Surg Pathol. 2007 Dec;31(12):1902-12.

Subungual melanoma (SUM) is an uncommon variant of melanoma that is often difficult to diagnose, both clinically and pathologically. In an attempt to provide pathologic clues to diagnosis, especially in early lesions or small biopsies, and to provide practical advice to pathologists in reporting, the clinicopathologic features of 124 cases of SUM were reviewed, the largest series reported to date. The features of 28 cases of subungual melanoma in situ (MIS), comprising 4 cases of MIS and 24 cases where areas of MIS were present adjacent to dermal-invasive SUMs, were compared with those of a similar number of acral nevi to identify useful distinguishing features. The median age of the patients was 59 years and the most common site was the great toe (24%). Nine percent of cases were AJCC stage 0, 14% were stage I, 41% were stage II, 32% were stage III, and 4% were stage IV at initial diagnosis. The commonest histogenetic subtype was acral lentiginous (66%), followed by nodular (25%) and desmoplastic (7%). The majority of tumors were locally advanced at presentation with 79% being Clark level IV or V. The median Breslow thickness was 3.2 mm. The median mitotic rate was 3 per mm and 33% of cases demonstrated primary tumor ulceration. Seven of 29 patients (24%) who underwent a sentinel lymph node biopsy had nodal disease. Multivariate Cox-regression analysis showed higher disease stage to be the only significant predictor of shortened survival. In comparison to acral nevi, MIS more frequently showed lack of circumscription, a prominent lentiginous growth pattern, predominance of single cells over nests, moderate-to-severe cytologic atypia, a dense and haphazard pagetoid intraepidermal spread of melanocytes, and the presence of junctional/subjunctional lymphocytes ("tumor infiltrating lymphocytes"). Tumor infiltrating lymphocytes have not been highlighted previously as a feature of subungual MIS and represent a useful diagnostic clue. Guidelines for the reporting of SUMs are also presented. Knowledge and recognition of the pathologic features of SUMs and the important features that distinguish them from nevi should reduce the frequency of misdiagnosis.
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Admin2 · Feb 2, 2008

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adavies · Feb 8, 2008

Does anyone have a quick way to diagnose a subungual melanoma?

drsarbes · Feb 8, 2008

Hi Adavies:

Just saw this post...from NOV 2007! Time flies!

In any event, I fell it's better to err on the conservative side. If you see a pigmented lesion under or at the nail border that is fairly NEW or has changed (or if the patient has just noticed it but is unsure of the chronicity) I would biopsy.

The first thing I do for SubUngual pigmentation is to make sure it is not just an old hematoma from a long forgotten toe stubbing. If you can currette it away (even partially) then obviously it is not pigmented. Leave it.

For all others, I would biopsy. If I have a patient with numerous nevi or "moles" I approach it differently. If they are all fairly consistent in color, texture, size and border definition then I leave them. If one stands out, biopsy.

I just had one three weeks ago. I had the patient scheduled for a 1st MTPJ implant and she had numerous pigmented lesions on both feet. One, however, on the lateral border of the 5th MTPJ was more bluish-darker than the rest, slightly raised and somewhat mottled in appearance with about 25% of the border "hazy". This type should be biopsied.

I have had two come back melanoma. Both on the Hallux. One subungual, one just on the epinychium. One patient did not make it to five years.

Hope that helps

Steve

adavies · Feb 13, 2008

Hi Steve,

thanks for the reply.
It's one of those things like a red bus, nothing for ages, then they all arrive at once!

AD

NewsBot · May 26, 2017

Cancer patient receives £178k for 'fungal nail' misdiagnosis

Experts agreed that "it was an abnormal nail and suggestive of malignancy" at the initial GP visit and that "its appearance was not consistent with fungal infection".
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NewsBot · Nov 19, 2017

Subungual melanoma is not so rare: Report of four cases from India.
Singal A, Pandhi D, Gogoi P, Grover C.
Indian Dermatol Online J 2017;8:471-4

Subungual melanoma (SUM) is an uncommon form of acral melanoma that arises within the nail matrix. The incidence for acral melanomas is similar worldwide, however, the proportion is higher in dark-skinned individuals. The subungual form represents approximately 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. No specific figures are available from the Indian subcontinent; however, the authors could trace three anecdotal case reports published over the last two decades. A general reluctance to biopsy a nail lesion to confirm the diagnosis may be contributing to the missed diagnosis. We report four cases of SUM of the big toenails seen over a period of 2.5 years. They were three women and one man with an age ranging from the 4th to 7th decade and disease duration of 6–18 months. The lesion involved the big toe in all and two patients had liver and lymph node metastasis at the time of presentation. Awareness among dermatologists regarding clinical manifestations, high index of suspicion for acral pigmented lesions, and nail bed biopsy may help in the early diagnosis and management and can prevent mortality.
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NewsBot · Aug 22, 2018

Nail apparatus melanoma: dermoscopic and histopathologic correlations on a series of 23 patients from a single centre.
Starace M et al
J Eur Acad Dermatol Venereol. 2018 Jan;32(1):164-173.

BACKGROUND:
Nail apparatus melanoma (NAM) is an uncommon tumour, and there are few studies focused on its dermoscopic features.

OBJECTIVE:
The aims of our study were to evaluate the diagnostic accuracy of dermoscopy in NAM. A diagnostic algorithm for adult patients with suspected NAM is proposed.

METHODS:
We collected NAM dermoscopic images of patients with a proven histopathology from 2008 until 2015. Clinical and dermoscopic images were blindly examined by two dermatologists, and correlations between histopathological aspects and dermoscopic features were investigated.

RESULTS:
We retrospectively collected NAM dermoscopic images associated with a proven histopathology of 23 Caucasian patients. Only cases with available both preoperative dermoscopic images and bioptic specimens were included. Seventeen women and six men were included. The mean age at diagnosis was 63 years (range 18-92).

CONCLUSION:
We created an algorithm to indicate the correct way to follow an adult patient with suspected NAM. This algorithm may ameliorate management in case of suspected NAM and possibly facilitate an early diagnosis.
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NewsBot · Mar 15, 2021

Retrospective Analysis of Nail Biopsies Performed Using the Medicare Provider Utilization and Payment Database 2012-2017
Yu Wang, Shari R Lipner
Dermatol Ther. 2021 Mar 4

Subungual melanoma (SUM) is subset of acral melanoma that develops within the nail unit and is associated with a poor prognosis. Nail biopsy is the only way to definitively diagnosis SUM. To analyze the Medicare database for nail biopsy utilization and to compare the annual nail biopsy rate with the estimated incidence of SUM in the United States (US). A retrospective study on nail biopsy data was performed using the Medicare Provider Utilization and Payment Database 2012-2017. The number of nail biopsies performed per 100 000 people was compared to SUM incidence per 100 000 people. Podiatrists, dermatologists, other physicians, and NP/PAs respectively performed 12.12, 0.42, 0.08, 0.07 nail biopsies per 100 000 people annually. Dermatologists performed adequate nail biopsies to cover the minimum (0.7%), but not the maximum (3.5%) estimated incidence of SUM. Only 0.28% and 1.01% of general dermatologists and Mohs surgeons, respectively, performed nail biopsies in 19/50 (38.00%) states and 69/929 (7.42%) zip codes. Limitations Nail biopsies on patients less than 65 years, and those with no or commercial health insurance were not analyzed. Very few dermatologists performed nail biopsies in the Medicare database. Increased efforts are needed to educate dermatologists on nail surgery
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NewsBot · Oct 9, 2021

Subungual Melanoma: A Single Institution Experience
Christopher J LaRocca et al
Med Sci (Basel). 2021 Sep 15;9(3):57

Despite the changing paradigms of melanoma treatment in recent years, there remains a relative paucity of data regarding subungual melanoma in the literature. From 2002-2018, 25 patients with subungual melanoma were surgically treated at our facility. A retrospective chart review was conducted to collect relevant demographic, clinical, pathologic, and outcomes data. The median age at diagnosis was 69 years. Most patients (60%) were male, and the melanoma lesion was most often located on the foot (68%). Acral-lentiginous was the most common histologic subtype (59%), and the median Breslow thickness was 3.4 mm. Fifteen patients (63%) underwent a sentinel lymph node biopsy as part of their surgical resection, and four of these patients (27%) had metastatic disease in the lymph nodes. In total, 10 patients underwent lymph node dissection of the involved basin. The median follow up was 21 months in this patient population. Age, gender, tumor location, ulceration, and lesion histology were not significantly associated with recurrence free survival (RFS). Increasing Breslow thickness was found to be significantly associated with shorter RFS (HR: 1.07, CI: 1.03-1.55). In total, 13 patients developed a disease recurrence, and RFS rates were 66% at 1 year and 40% at 3 years. Additionally, 91 and 37% of patients were alive at one year and three years, respectively. Subungual melanomas are rare lesions that often have a more advanced stage at diagnosis, which contributes to the poor prognosis of these cutaneous malignancies.
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NewsBot · Jan 30, 2023

Amelanotic subungual melanoma and chilblains
Karen Manuelyan, Bernadette De Silva and Rakhi Singh-Raghunath1
Source

A female patient in her 50s presented with blue discolouration of several toes and with single nail dystrophy affecting the little toenail. The nail changes were considered to be secondary to poor circulation and chilblains, which led to delay in the diagnosis of amelanotic subungual melanoma.
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