Primary melanoma of the hand: An algorithmic approach to surgical management

Reconstruction after Mohs Surgery for Digit Melanoma: Description of Techniques and Postoperative Limb Function

Introduction

Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma.

Materials and Methods

A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure.

Results

Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/-17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1-95 months). The average defect size was 5.79 +/-4.54 cm2. Reconstruction was performed 0-4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61).

Conclusion

Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.

Salvaging the Digit in Invasive Subungual Malignancies Using a Triple Technique under Awake Local Anesthesia

Introduction

Amputation for subungual malignancy (SUM) was thought to be the gold standard in preventing recurrence and metastasis. The rationale behind this aggressive treatment was never based on scientific evidence. Even though multiple recent studies supported more conservative management by illustrating successful results of the digit salvage technique, especially for "in situ" SUM, this salvage approach is not well supported for the more aggressive type of the "invasive" SUM; herein, we salvaged two cases of "invasive" SUM. Case Presentation. We present two cases of invasive SUM without radiographic evidence of intraosseous involvement, where we avoided digit amputation for both invasive subungual squamous cell carcinoma of the thumb and invasive subungual melanoma of the ring finger. Both were salvaged by using a triple technique under awake local anesthesia which included (I) radical excision of the nail bed unit including both eponychium and periosteum, (II) dorsal cortical bone shaving using a high-speed burr for the distal phalanx, and (III) flap coverage. Brunelli flap was used for the thumb in the first case, and V-Y plasty combined with proximal nail fold advancement flap was used for the ring finger in the second case. There was no evidence of local or distant recurrence, with a good functional outcome after 2.5 years in the first case and 2 years in the second.

Conclusion

Ensuring complete resection with negative margins while preserving the functionality of the affected digit is considered to be the optimal challenge in treating "invasive" subungual malignancies. These two case reports contribute by reporting a successful digit salvage. The safety of this procedure could be confirmed by larger series and longer follow-up periods.

Melanoma of the Hands and Feet (With Reconstruction)

Melanomas only account for 4% of all dermatologic cancers yet are responsible for 80% of deaths. Notably, melanomas of the hand and foot have a worse prognosis when compared with melanomas of other anatomic regions. Likely this is due to intrinsic biologic characteristics, delayed diagnosis, difficult surgical excision due to delicate anatomy, and lack of definitive diagnostic and therapeutic guidelines. The most common locations of melanoma of the hand, in order of decreasing frequency, are subungual area, dorsal surface, and palmar surface. The most common locations of melanoma of the foot are the plantar surface, dorsal surface, and subungual area, in decreasing frequency. Diagnosis of melanoma of the hand and foot can be difficult because the traditional "ABCDE" (asymmetric shape, border, color, diameter, evolution) rules do not apply. Newer acronyms have been proposed in literature including "CUBED" (colored, uncertain, bleeding, enlarged, delayed) and "ABC rule for Subungual Melanoma." Once diagnosed, treatment is primarily surgical excision and reconstruction. The goal for the surgeon is to maintain the function and anatomy of the hand or foot.

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.

Japanese Dermatological Association Guidelines: Outlines of guidelines for cutaneous melanoma 2019

With consideration of the ongoing developments in treatment options for cutaneous melanoma, the Japanese Skin Cancer Society published the first guidelines for cutaneous melanoma in 2007 and later revised them in 2015. Here, we report on an English version of the 2019 Japanese Melanoma Guidelines. In this latest edition, all processes were carried out according to the Grading of Recommendations, Assessment, Development and Evaluation system. A comprehensive published work search, systematic review and determination of recommendations in each clinical question were performed by a multidisciplinary expert panel consisting of dermatologists, a plastic and reconstructive surgeon, and a radiation oncologist. The advent of novel agents, such as immune checkpoint inhibitors and molecular-targeted agents, has drastically changed the nature of treatment for adjuvant and advanced-stage diseases among melanoma patients worldwide. Additionally, recent reports of clinical trials regarding surgical procedures and a better understanding of molecular biology and tumor immunology in clinical types of melanoma have had an impact on clinical practise. Based on these viewpoints, eight relevant clinical questions were raised in this report that aim to help clinicians select the appropriate therapeutic approach.

Subungual Melanoma

Subungual melanoma is a rare form of melanoma that presents a unique set of challenges largely based on the complex anatomy of the nail unit. Subungual melanoma often first appears with longitudinal melanonychia. Thus, practitioners must have a high clinical suspicion in any patient with longitudinal melanonychia and a low threshold for a biopsy. The "ABCDEF" guide can be a useful tool to aid in screening any lesion of the nail bed. The authors recommend that biopsies of the nail unit be performed by a surgeon with an in-depth understanding of the pathoanatomy of subungual melanoma.

Subungual Tumors: An Algorithmic Approach

The presentation of benign and malignant subungual tumors often follows a final common pathway of nonspecific nail deformity; as such, delays in diagnosis are common. Therefore, it is imperative to have a high degree of suspicion for malignant lesions and an organized approach to subungual tumors. To that end, we present a diagnostic algorithm encompassing the most common benign and malignant subungual tumors, along with a summary of the presentation, imaging, and treatment of these lesions.

The rule of 10s versus the rule of 2s: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas

Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s. Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs with paraffin sections decrease complications of surgery of specialty site melanomas by detecting upstaging and confirming complete tumor removal with comprehensive microscopic margin assessment before reconstruction. This article reviews information important for counseling melanoma patients about surgical treatment options and for developing consensus guidelines with clear indications for MMS-I or slow Mohs.

Guidelines of care for the management of primary cutaneous melanoma

The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.