Pathologic fracture secondary to subungual melanoma

Melanoma of the Nail Apparatus: An Analysis of Patients' Survival and Associated Factors

BACKGROUND

There are no proper management guidelines for nail apparatus melanoma (NAM).

OBJECTIVE

This study aimed to describe the clinical features, the presence of locoregional and distant metastases and disease-free and overall survival of NAM treated at our institution.

METHODS

A retrospective cohort review of patients with single, primary localized histopathologically confirmed NAM was performed. Collected data consisted of patients' characteristics and tumor features. In addition, local recurrence, locoregional metastases, distant metastases, disease-free survival (DFS) and overall survival (OS) were used as the main outcomes in our analysis.

RESULTS

Thirty patients with NAM were included. The overall survival (OS) in our patients at 5 and 10 years was 85.6 and 73.4%, respectively. DFS was significantly higher in patients with primary tumor location in the hand and without tumor-infiltrating lymphocytes (p value = 0.01 and 0.04, respectively). The patients with in situ melanoma or Breslow thickness <1 mm had a significantly higher chance of DFS and OS (90.0 and 94.1% at 5 years, respectively) than those with thicker NAM (58.3 and 55.6% at 5 years, respectively). A total of 53.3% of 30 patients underwent primary excision and covering with a full-thickness skin graft, while 13.3% of our 30 patients underwent digit amputation. The patients who underwent excision and covering with a full-thickness skin graft showed a complete overall survival (100% at 5 years).

CONCLUSION

Primary tumor location in the hand and lower tumor thickness might be correlated with better patients' survival. The study results suggest that total amputation might not be necessary in all NAM cases.

Retrospective analysis of nail biopsies performed using the Medicare Provider Utilization and Payment Database 2012 to 2017

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. Our objectives were 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. A retrospective study on nail biopsy data was performed using the Medicare Provider Utilization and Payment Database 2012 to 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 of our study were that nail biopsies on patients less than 65 years, and those with no or commercial health insurance were not analyzed. In sum, very few dermatologists performed nail biopsies in the Medicare database. Increased efforts are needed to educate dermatologists on nail surgery.

Treatment of pathologic fractures

Pathologic fractures occur in bone weakened by a disease process. In the hand, the most common cause of pathologic fracture is a solitary enchondroma, although many other less common causes exist, including bone cysts, benign and malignant tumors, and other rarer entities. Arriving at a correct diagnosis is the key to successful treatment. If the fracture seems the result of a benign process, the fracture can be allowed to heal prior to definitive treatment of the underlying lesion. Fractures associated with aggressive or malignant lesions require more urgent treatment, although the overall prognosis for pathologic fracture due to malignancy is poor.

Metastatic malignant melanoma to the foot and ankle: a review of the literature and case report

The lower extremity is a frequent site for malignant melanomas. However, skeletal metastases involving the foot and ankle are a rarity. Nearly all documented cases of secondary pedal bone metastasis have originated from a primary subungual melanoma. The following case study illustrates an unusual skeletal metastasis to the foot and ankle arising from a primary malignant melanoma of the torso.