Plantar melanoma: Results of treatment in three population groups

Early detection of acral melanoma: A review of clinical, dermoscopic, histopathologic, and molecular characteristics

Acral lentiginous melanoma is a distinct subtype of melanoma on acral skin. Patient presentation at later stages and delayed diagnosis by physicians contribute to a worse associated prognosis and survival rate. Despite our progress in understanding the key features of this disease, the diagnosis of early-stage acral melanoma is still challenging. It is essential to integrate clinical, dermoscopic, and histologic findings in the diagnosis of acral lentiginous melanoma. In addition, molecular studies can be helpful. In this review, we have summarized our current understanding of this disease entity from articles that were published between 1969 and 2018. We have outlined clinical and dermoscopic features as well as pathologic and molecular findings regarding acral melanoma and have presented an algorithm for diagnosis. Understanding and integrating these characteristics may assist clinicians in the early detection of acral melanomas.

Results of second-stage screening for skin cancers in Oita Prefecture, Japan

We performed skin cancer screenings for 2 or 3 days annually from 2006 through 2013 in Oita Prefecture, Japan. Screening of approximately 3000 people in total allowed us to identify and treat several skin cancers, including five cases of malignant melanoma, four of squamous cell carcinoma, 16 of basal cell carcinoma, 11 of Bowen's disease, 17 of actinic keratosis, one of extramammary Paget's disease and one of metastatic breast carcinoma. The sensitivity and specificity for the category defined by an identified lesion associated with risk of cancer and requiring further examination (category C) were 92.7% and 95%, respectively. We cannot estimate the outcome of our skin cancer screenings in terms of cancer mortality because of the small number of subjects examined and the brief follow-up period. However, we did estimate the effectiveness of these screenings in terms of stages or sizes of cancerous lesions. The relative numbers of subjects with malignant melanoma at various clinical stages, identified during skin cancer screenings and during a routine visit to our hospital, were significantly different. We also compared, statistically, the sizes of lesions in Bowen's disease that were found during cancer screenings and during a direct visit to our hospital. The former lesions were smaller than the latter. Our data suggest the benefits of our skin cancer screenings and the importance of campaigns and education to encourage people to visit dermatologists for the detection of skin cancers at an early stage.

[Local recurrence and survival in acral lentiginous melanoma comparing 3D histology and conventional histology]

BACKGROUND

Surgical treatment of acral lentiginous melanomas with wide excisional margins as recommended often requires amputation of distal extremities. The current study analyzes, if smaller excisions in combination with a complete histological evaluation of the excisional margins (3D histology) have a negative impact on the prognosis.

PATIENTS AND METHODS

304 patients were retrospectively evaluated. 192 patients with reduced excisional margins followed by 3D histology (group A) were compared with 112 patients treated with conventional wide margins (group B). The outcome of both groups was compared.

RESULTS

The median tumor thickness was higher in group A (p = 0.022) and ulcerations occured more frequently (p = 0.017). The median excisional margin was 8 mm in group A and 20 mm in group B (p < 0.0001). 10.9 % (4.2 % invasive) of group A und 8.9 % (4.5 %invasive) of group B (p = 0.577) developed a local recurrence in a median of 40 months.The melanoma specific 10-year survival was 66.8 % in group A und 63.4 % in group B(p = 0.531). Survival of patients with or without local recurrence showed no difference(p = 0.643).

CONCLUSIONS

Excision with small margins followed by 3D histology is not inferior to conventional surgery with wide margins concerning the rate of local recurrences and has no negative impact on prognosis or the further course of the disease. Local recurrences are rare and do not influence the survival.

A rare form of melanoma masquerading as a diabetic foot ulcer: a case report

Background. Acral lentiginous melanoma (ALM) is a less-common form of melanoma in US, and it accounts for about 5% of all diagnosed melanomas in US. ALM is often overlooked until it is well advanced because of the lesion's location and its atypical appearance in the early stages. We present a case of ALM initially presented as a diabetic foot ulcer. Case Report. An 81-year-old man initially presented to the primary care clinic with a right foot diabetic ulcer. There was a large plantar, dark-colored ulcer that bled easy. Initial excision biopsy revealed Clark's Level IV ALM. Subsequent definitive wide excision and sentinel node biopsy confirmed ALM with metastasis to inguinal lymph nodes (stage IIIb). The treatment included wide margin excision of the lesion with en bloc amputations of 4th and 5th toes, followed by adjuvant chemotherapy. Discussion. The development of ALM may potentially relate to diabetes as a reported higher prevalence of diabetes with ALM patients. Conclusion. The difficulty in early diagnosing of ALM remains as a formidable challenge particularly in diabetic patients who commonly develop plantar foot ulcers due to the diabetic neuropathy. This case reiterates the importance of a thorough foot exam in such patients.

Reconstructive options for defects after melanoma excision in the foot and ankle region

Cutaneous wounds created by excision of primary cutaneous melanoma localized to the foot and ankle can be challenging to reconstruct. A wide range of coverage techniques are available for wound coverage. The techniques we have found useful in this regard include skin grafts and flaps, as well as specialized wound dressings. In this techniques report, we describe the specialized anatomic surface subunits of the foot and ankle and the reconstructive coverage methods we have found useful for each site.

Acral lentiginous melanoma: a case control study and guidelines update

Background. Malignant melanoma incidence is increasing dramatically. We report herein a case of the rarest acral lentiginous type. Case Report. A 58-year-old man presented with a melanoma resembling lesion over the sole of his right foot, measuring 15-20 mm in diameter. An excisional biopsy with a narrow (2 mm) margin of surrounding skin was obtained. Histological findings were consistent with a diagnosis of acral lentiginous melanoma. Sentinel lymph node biopsy was also performed and micrometastases were not identified in frozen-section examination. According to the AJCC system, the tumor stage was IB (T2aN0M0). A wide local excision of the biopsy scar with a margin of 2 cm was performed. A split-thickness thick skin graft was used to reconstruct the excisional defect. During an 18-month followup, no local or distant recurrence has been observed. This paper aims to extract an updated rational approach to the management of this disease out of an enormous body of knowledge.

Acral lentiginous melanoma of the foot and ankle: A case series and review of the literature

Background

Acral lentiginous melanoma (ALM) is an uncommon, cutaneous malignant tumour which may arise on the foot. Its relative rarity, atypical appearance and late presentation frequently serve as poor prognostic indicators.

Methods

At a tertiary skin tumour centre, a retrospective review was undertaken of all patients diagnosed with the tumour at the level of ankle or below.

Results

Over a six year period, 27 cases (20 female, 7 male) were identified with positive histology confirming the disease. The age ranged from 35–96 years of age (mean 62.7 years). The majority of the cohort were white (59%) with plantar lesions (62%). 33% of patients were initially were diagnosed incorrectly. The average time taken from the point of recognition, by the patient, to the lesion being correctly diagnosed was around 13.5 months.

Conclusion

Earlier diagnosis of ALM requires education at both a patient and practitioner level.

Skin cancer in skin of color

Skin cancer is less common in persons with skin of color than in light-skinned Caucasians but is often associated with greater morbidity and mortality. Thus, it is crucial that physicians become familiar with skin cancer in persons of color so as to maximize the likelihood of early detection of these tumors. In dark-skinned ethnic groups, squamous cell carcinoma is most common; squamous cell carcinoma and melanoma usually occur on nonsun-exposed sites; and ultraviolet radiation is not an important etiologic factor for skin cancer with the exception of basal cell carcinoma. Races of intermediate pigmentation, such as Hispanics and Asians, share epidemiologic and clinical features of dark-skinned ethnic groups and Caucasians. Skin cancers pose a significant risk in skin of color and clinicians should focus on preventive measures in these groups such as regular skin exams, self-examination, public education, and screening programs.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the epidemiology and unique clinical features of skin cancer in skin of color and be aware of strategies to prevent skin cancer in skin of color.

Diagnosis and treatment of malignant melanoma of the foot

BACKGROUND

Patients diagnosed with melanoma of the foot have been reported to have a poor prognosis. We reviewed our experience at a tertiary-care medical clinic to determine the disease course in patients diagnosed with melanoma of the foot.

METHODS

A retrospective review was performed of 38 patients with a diagnosis of primary or locally recurrent melanoma of the foot treated between January, 1988, and July, 2004. The main outcome measures included methods of diagnosis, clinical and histopathologic features, and patterns of recurrence.

RESULTS

The mean age at diagnosis was 61 years; most were women (58%) and Caucasian (95%). The average time to diagnosis was 17 months. Initial clinical diagnosis had been considered benign in 12 (32%). The median Breslow thickness was 1.75 mm, T1 lesions were the most common, and acral lentiginous melanoma accounted for 42%. Thirteen patients (34%) had ulcerated lesions. Sentinel lymph node biopsy specimens of 25 patients identified four (16%) with metastatic disease. Surgical complications occurred in 12 patients, usually after skin graft or soft-tissue flap reconstruction. Systemic recurrence developed in six patients, four of whom also had regional recurrence.

CONCLUSIONS

Most patients were elderly Caucasian women and most presented with early-stage disease, but diagnosis can be difficult and a subgroup presented with thick melanomas. Reconstructive surgical procedures had a high rate of complications; however, overall functional outcomes were good. Stage of cancer at diagnosis was associated with systemic metastases.

Advanced presentation of melanoma in African Americans

BACKGROUND

Melanoma in African Americans is rare, and the diagnosis is often delayed, leading to advanced presentation and poor prognosis.

OBJECTIVE

The purpose of this retrospective study is to determine whether African American patients diagnosed with melanoma at the Washington Hospital Center were initially seen with more advanced disease than white patients.

METHODS

A retrospective chart review was performed on 36 African American patients who were diagnosed and/or treated for melanoma at the Washington Hospital Center between 1981 and 2000. Data obtained included patient age at presentation, sex, Breslow's depth and histologic subtype, stage at presentation, and tumor location. These data were compared with information obtained from white patients with melanoma during this period.

RESULTS

A total of 649 African American and white patients were treated for melanoma at the Washington Hospital Center between 1981 and 2000. Of these, 36 (6.1%) patients were African American. African American patients were more likely to initially be seen with stage III/IV disease (32.1%) compared with (12.7%) the white patients initially seen with these disease stages. Of the white patients 60.4% were initially seen with melanoma in situ/stage I disease compared with 39.3% of the African American patients. The 5-year survival rate was 58.8% in African Americans compared with 84.8% in whites.

CONCLUSIONS

In our series, African Americans are more likely than whites to be initially seen with advanced disease and have a subsequent worse prognosis. Physician training and patient education campaigns are crucial to improving the poor prognosis associated with melanoma in the African American community.

Malignant melanoma in South Africans of mixed ancestry: a retrospective analysis

Little is known about the behaviour of melanoma in patients of mixed ancestry. A retrospective analysis of 844 consecutive patients presenting with melanoma over a 12-year period was performed. Forty patients (4.8%) were of mixed ancestry. The data evaluated included patient age, gender, delay in presentation, presenting stage, anatomical distribution, histology, management and outcome. The mean age at presentation was 52.8 years. Twenty-seven patients were female. The mean delay in presentation was 1.54 years. Seventy per cent of melanomas were confined to the extremities, of which one-third were plantar in origin. The most common histological variant, affecting 13 patients (32.5%), was acral lentiginous melanoma; 12.5% of patients presented with in situ (Stage 0) disease, 17.5% with Stage I disease, 22.5% with Stage II disease, 27.5% with Stage III disease and 7.5% with Stage IV disease. Twenty-seven patients (67.5%) remained alive at the end of the study after a median follow-up of 5.58 years, whilst 11 (27.5%) died after a median of 2.42 years. The median survival was 3.92 years. Although the histological type and anatomical distribution reflect the disease pattern of black populations, the overall 5-year survival of 74% is similar to that seen in white populations. An education programme is needed to improve melanoma awareness in mixed race populations.

Acral lentiginous melanoma mimicking benign disease: the Emory experience

BACKGROUND

Plantar and subungual melanoma exhibits a higher misdiagnosis rate relative to other anatomic sites. Misdiagnosis and delay in diagnosis are statistically associated with poorer patient outcome. Awareness of atypical presentations of acral melanoma may, thus, be important to decrease misdiagnosis rates and improve patient outcome.

METHODS

We conducted a retrospective case review of plantar or lower-extremity subungual melanoma performed at Winship Cancer Center, a tertiary care, referral center affiliated with Emory University, between 1985 and 2001.

RESULTS

A total of 53 cases of plantar or lower-extremity subungual melanoma were identified. Of 53 cases with a final diagnosis of melanoma, 18 were initially misdiagnosed. Misdiagnoses included wart, callous, fungal disorder, foreign body, crusty lesion, sweat gland condition, blister, nonhealing wound, mole, keratoacanthoma, subungual hematoma, onychomycosis, ingrown toenail, and defective/infected toenail. Of the 18 misdiagnosed cases, 9 were clinically amelanotic.

CONCLUSION

Awareness that amelanotic variants of acral melanoma may assume the morphology of benign hyperkeratotic dermatoses may increase the rate of correct diagnosis and improve patient outcome.

Current concepts in the management of patients with melanoma

Melanoma is a significant health problem. Despite public education and free cancer screenings, the incidence and mortality of melanoma continues to rise; however, many currently diagnosed melanomas are thin lesions, suggesting that education and awareness is having an impact. In addition, there are still subsets of patients who need increased surveillance in order to increase their survival. Although large congenital nevi may be precursors of melanoma, small and medium congenital nevi have an insignificant risk for melanoma development. Large congenital nevi, which are axial in location, appear to be more likely to develop melanoma and are associated with melanocytosis and melanoma of the CNS, both of which portend a poor prognosis. Recently, the recommended margins of excision have become more conservative so that many of the surgical defects can be closed primarily. Lymphoscintigraphy and sentinel node biopsy have replaced elective node dissections, thus decreasing the morbidity associated with the surgical management of melanoma. Although controversy still exists as to whether or not sentinel lymph node biopsy alters a patient's prognosis, it has been shown to be a powerful prognostic indicator. Although most melanomas are managed by routine surgical excision, other modalities are sometimes employed. For example, cryosurgery or radiation therapy may be indicated in the frail, elderly individual with a large facial lentigo maligna. Mohs surgery is the treatment of choice for head and neck melanomas and those located in areas where maximum preservation of tissue is required and for desmoplastic and acral lentiginous melanomas. Much more work remains in the area of adjuvant therapy, chemotherapy, and immunotherapy. Dacarbazine remains the drug of choice in disseminated melanoma, but remissions are usually short lived. Interleukin and biochemotherapy has yielded good results but the percentage benefiting is small. Although high dose interferon increases disease-free and overall survival in some patients, it remains a controversial drug which is not easily tolerated. In the new staging system for melanoma, ulceration is second only to Breslow's thickness. In transit (satellite) lesions have also been included in this new system. The new system also recognizes that patients with only microscopic metastatic nodal disease fare better than patients with clinically enlarged metastatic nodes and that it is the number of nodes involved with metastases, not their size, that determines the patient's prognosis. Except for lesions <1mm thick, the Clark's level of invasion has been de-emphasized.