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A Hidden Threat: Subungual Melanoma in Hand

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DOI: 10.4236/ss.2012.32014    13,649 Downloads   22,394 Views   Citations


Subungual melanoma, a relatively uncommon disease, has a worse prognosis than cutaneous melanoma in other sites. Both this life-threatening disease and its treatment cause cosmetic and functional impairment to the patient. The diagnosis is often delayed and resulting an advanced disease at presentation. The important clinical manifestation, diagnosis and latest treatments for subungual melanoma are reviewed. Electronic databases of Medline, PubMed, and the Cochrane library were searched with the key word “subungual melanoma”. A clinical scoring system is proposed by the authors to stratify patients to undergo biopsy, making earlier diagnosis of this disease possible. The latest trend of treatment involves wide local excision at a more distal level of the affected digit, in contrast to radical amputation of the digit in the past. Studies have shown that this does not decrease the survival nor increase local recurrence, but reduces the functional impairment for the patient. This review aims to summarise the approach to subungual melanoma for clinicians, so that they can recognise and diagnose this disease early and generate the best functional and cosmetic outcome for the patients.

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The authors declare no conflicts of interest.

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C. Tang, B. Fung and C. Lung, "A Hidden Threat: Subungual Melanoma in Hand," Surgical Science, Vol. 3 No. 2, 2012, pp. 78-83. doi: 10.4236/ss.2012.32014.


[1] K. Blessing, N. M. Kernohan and K. G. M. Park, “Subungual Malignant Melanoma: Clinicopathological Features of 100 Cases,” Histopathology, Vol. 19, No. 5, 1991, pp. 425-429. doi:10.1111/j.1365-2559.1991.tb00232.x
[2] A. I. Riker, N. Zea and T. Trinh, “The Epidemiology, Prevention, and Detection of Melanoma,” The Ochsner Journal, Vol. 10, 2010, pp. 56-65.
[3] Banfield and Dawber, “Nail Melanoma: A Review of the Literature with Recommendations to Improve Patient Management,” British Journal of Dermatology, Vol. 141, No. 4, 1999, pp. 628-632. doi:10.1046/j.1365-2133.1999.03099.x
[4] K. E. Thai, R. Young and S. Rd, “Nail Apparatus Melanoma,” Australasian Journal of Dermatology, Vol. 42, No. 2, 2001, pp. 71-83.
[5] V. K. Shukla and L. E. Hughes, “Differential Diagnosis of Subungual Melanoma from a Surgical Point of View,” British Journal of Surgery, Vol. 76, No. 11, 1989, pp. 1156-1160. doi:10.1002/bjs.1800761115
[6] Banfield, Redburn and Dawber, “The Incidence and Prognosis of Nail Apparatus Melanoma. A Retrospective Study of 105 Patients in Four English Regions,” British Journal of Dermatology, Vol. 139, No. 2, 1998, pp. 276-279. doi:10.1046/j.1365-2133.1998.02365.x
[7] R. H. Patterson and E. B. Helwig, “Subungual Malignant Melanoma: A Clinical-Pathologic Study,” Cancer, Vol. 46, No. 9, 1980, pp. 2074-2087. doi:10.1002/1097-0142(19801101)46:9<2074::AID-CNCR2820460928>3.0.CO;2-K
[8] C. M. Balch, S. J. Soong, et al., “An Analysis of Prognostic Factors in 8500 Patients with Cutaneous Melanoma,” In: C. M. Balch, A. N. Houghton, G. W. Milton, A. J. Sober and S.-J. Soong, Eds., Cutaneous Melanoma, Lippincott, Philadelphia, 1992, pp. 165-187.
[9] W. A. G. Bruls, H. Slaper, J. C. Van Der Leun and L. Berrens, “Transmission of Human Epidermis and Stratum Corneum as a Function of Thickness in the Ultraviolet and Visible Wavelengths,” Photochemistry and Photobiology, Vol. 40, No. 4, 1984, pp. 485-494. doi:10.1111/j.1751-1097.1984.tb04622.x
[10] H. Takematsu, M. Obata, Y. Tomita, T. Kato, M. Takahashi and R. Abe, “Subungual Melanoma: A Clinicopathologic Study of 16 Japanese Cases,” Cancer, Vol. 55, No. 11, 1985, pp. 2725-2731. doi:10.1002/1097-0142(19850601)55:11<2725::AID-CNCR2820551134>3.0.CO;2-V
[11] D. A. Hudson, J. E. J. Krige, R. M. Strover and H. S. King, “Subungual Melanoma of the Hand,” Journal of Hand Surgery, Vol. 15, No. 3, 1990, pp. 288-290. doi:10.1016/0266-7681(90)90005-O
[12] M. M?hrle and H. M. H?fner, “Is Subungual Melanoma Related to Trauma?” Dermatology, Vol. 204, No. 4, 2002, pp. 259-261. doi:10.1159/000063354
[13] J. A. O’Leary, K. R. Berend, J. L. Johnson, L. S. Levin and H. F. Seigler, “Subungual Melanoma. A Review of 93 Cases with Identification of Prognostic Variables,” Clinical Orthopaedics and Related Research, Vol. 378, 2000, pp. 206-212.
[14] T. Cohen, K. J. Busam, A. Patel and M. S. Brady, “Subungual Melanoma: Management Considerations,” American Journal of Surgery, Vol. 195, No. 2, 2008, pp. 244-248. doi:10.1016/j.amjsurg.2007.03.010
[15] E. K. Levit, M. H. Kagen, R. K. Scher, M. Grossman and E. Altman, “The ABC Rule for Clinical Detection of Subungual Melanoma,” Journal of the American Academy of Dermatology, Vol. 42, No. 2, 2000, pp. 269-274.
[16] R. K. Scher and D. N. Silvers, “Longitudinal Melanonychia Striata,” Journal of the American Academy of Dermatology, Vol. 24, No. 6, 1991, pp. 1035-1036. doi:10.1016/S0190-9622(08)80136-3
[17] M. J. Quinn, J. E. Thompson, K. Crotty, W. H. McCarthy and A. S. Coates, “Subungual Melanoma of the Hand,” The Journal of Hand Surgery, Vol. 21, No. 3, 1996, pp. 506-511. doi:10.1016/S0363-5023(96)80371-6
[18] A. B. Ackerman, “Conventional Microscopy: Signs That Stamp Pigmented Melanocytic Nevi as Benign,” American Journal of Dermatopathology, Vol. 4, No. 5, 1982, pp. 461-466. doi:10.1097/00000372-198210000-00015
[19] T. Kato, Y. Usuba, H. Takematsu, N. Kumasaka, Y. Tanita, K. Hashimoto, Y. Tomita and H. Tagami, “A Rapidly Growing Pigmented Nail Streak Resulting in Diffuse Melanosis of the Nail. A Possible Sign of Subungual Melanoma in situ,” Cancer, Vol. 64, No. 10, 1989, pp. 2191-2197. doi:10.1002/1097-0142(19891115)64:10<2191::AID-CNCR2820641035>3.0.CO;2-D
[20] R. Baran and P. Kechijian, “Hutchinson’s Sign: A Reappraisal,” Journal of the American Academy of Dermatology, Vol. 34, No. 1, 1996, pp. 87-90. doi:10.1016/S0190-9622(96)90839-7
[21] B. S. Ruben, “Pigmented Lesions of the Nail Unit: Clinical and Histopathologic Features,” Seminars in Cutaneous Medicine and Surgery, Vol. 29, No. 3, 2010, pp. 148-158. doi:10.1016/j.sder.2010.06.008
[22] J. W. Kelly, J. M. Yeatman, C. Regalia, G. Mason and H. Ap, “A High Incidence of Melanoma Found in Patients with Multiple Dysplastic Naevi by Photographic Surveillance,” Medical Journal of Australia, Vol. 167, 1997, pp. 191-194.
[23] M. Izumi, K. Ohara, T. Hoashi, H. Nakayama, C.-S. Chiu, T. Nagai, J. Matsubayashi, K. Iwaya and K. Mukai, “Subungual Melanoma: Histological Examination of 50 Cases from Early Stage to Bone Invasion,” The Journal of Dermatology, Vol. 35, No. 11, 2008, pp. 695-703. doi:10.1111/j.1346-8138.2008.00551.x
[24] G. Massi, P. E. Leboit and E. Al, “Melanoma on Palms, Soles and Subungual Melanoma—Acral Melanoma,” In: D. Massi and P. Leboit, Eds., Histological Diagnosis of Nevi and Melanoma, Springer, 2004, p. 577. doi:10.1007/978-3-7985-1943-5
[25] R. A. Scolyer, J. F. Thompson, S. W. McCarthy, G. M. Strutton and D. E. Elder, “Incomplete Biopsy of Melanocytic Lesions Can Impair the Accuracy of Pathological Diagnosis,” Australasian Journal of Dermatology, Vol. 47, No. 1, 2006, pp. 71-73.
[26] A. Piris, M. C. Mihm Jr. and L. M. Duncan, “AJCC Melanoma Staging Update: Impact on Dermatopathology Practice and Patient Management,” Journal of Cutaneous Pathology, Vol. 38, No. 5, 2011, pp. 394-400. doi:10.1111/j.1600-0560.2011.01699.x
[27] J. Hutchinson, “Melanosis Often Not Black: Melanotic Whitlow,” British Medical Journal, Vol. 1, 1886, p. 491.
[28] K. M. Heaton, A. El-Naggar, L. G. Ensign, M. I. Ross and B. Cm, “Surgical Management and Prognostic Factors in Patients with Subungual Melanoma,” Annals of Surgery, Vol. 219, No. 2, 1994, pp. 197-204. doi:10.1097/00000658-199402000-00012
[29] K. G. M. Park, K. Blessing and K. Nm, “Surgical Aspects of Subungual Malignant Melanomas,” Annals of Surgery, Vol. 216, 1992, pp. 692-695. doi:10.1097/00000658-199212000-00012
[30] F. H. Sim, W. F. Taylor, D. J. Pritchard and S. Eh, “Lymphadenectomy in the Management of Stage I Malignant Melanoma: A Prospective Randomized Study,” Mayo Clinic Proceedings, Vol. 61, 1986, pp. 697-705.
[31] N. Cascinelli, A. Morabito, M. Santinami, R. M. Mackie and F. Belli, “Immediate or Delayed Dissection of Regional Nodes in Patients with Melanoma of the Trunk: A Randomised Trial,” Lancet, Vol. 351, No. 9105, 1998, pp. 793-796. doi:10.1016/S0140-6736(97)08260-3
[32] R. K. Finley 3rd, D. L. Driscoll, L. E. Blumenson and K. Cp, “Subungual Melanoma: An Eighteen-Year Review,” Surgery, Vol. 116, 1994, pp. 96-100.
[33] M. Moehrle, S. Metzger, W. Schippert, C. Garbe, G. Rassner and H. Breuninger, “‘Functional’ Surgery in Subungual Melanoma,” Dermatologic Surgery, Vol. 29, 4, 2003, pp. 366-374. doi:10.1046/j.1524-4725.2003.29087.x
[34] U. Veronesi, N. Cascinelli, J. Adamus, C. Balch, D. Bandiera, A. Barchuk, R. Bufalino, P. Craig, J. De Marsillac, J. C. Durand and E. Al, “Thin Stage I Primary Cutaneous Malignant Melanoma. Comparison of Excision with Margins of 1 or 3 cm,” New England Journal of Medicine, Vol. 318, 1988, pp. 1159-1162. doi:10.1056/NEJM198805053181804
[35] C. M. Balch, S.-J. Soong, T. Smith, M. I. Ross, M. M. Urist, C. P. Karakousis, W. J. Temple, M. C. Mihm, R. L. Barnhill, W. R. Jewell, et al., “Long-Term Results of a Prospective Surgical Trial Comparing 2 cm vs. 4 cm Excision Margins for 740 Patients with 1 - 4 mm Melanomas,” Annals of Surgical Oncology, Vol. 8, No. 2, 2001, pp. 101-108.
[36] J. M. Thomas, J. Newton-Bishop, R. A’hern, G. Coombes, M. Timmons, J. Evans, M. Cook, J. Theaker, M. Fallowfield, T. O’neill, W. Ruka and J. M. Biss, “Excision Margins in High-Risk Malignant Melanoma,” New England Journal of Medicine, Vol. 350, 2004, pp. 757-766. doi:10.1056/NEJMoa030681
[37] D. L. Morton, J. F. Thompson, A. J. Cochran, N. Mozzillo, R. Elashoff, R. Essner, O. E. Nieweg, D. F. Roses, H. J. Hoekstra, C. P. Karakousis, D. S. Reintgen, B. J. Coventry, E. C. Glass and H. J. Wang, “Sentinel- Node Biopsy or Nodal Observation in Melanoma,” New England Journal of Medicine, Vol. 355, 2006, pp. 1307-1317.
[38] J. Weber, “Immunotherapy for Melanoma,” Current Opinion in Oncology, Vol. 23, 2011, pp. 163-169. doi:10.1097/CCO.0b013e3283436e79

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