Surgical management of subungual melanoma: Mayo Clinic experience of 124 cases

Jesse T. Nguyen, Karim Bakri, Emily C. Nguyen, Craig H. Johnson, Steven Lawrence Moran

Research output: Contribution to journalArticle

22 Citations (Scopus)

Abstract

BACKGROUND: Optimal surgical management of subungual malignant melanoma (SMM) has been debated. METHODS: Our tumor registry was reviewed for surgically treated cases of SMM from 1914 to 2010. Resection levels were compared with outcome. RESULTS: During a 96-year period, 124 cases of SMM were identified (65 men and 59 women). Mean age at diagnosis was 58 years. Mean length of symptoms before diagnosis was 2.2 years. Lesions occurred on the hand (n = 79) and foot (n = 45). The thumb (33.8%) and hallux (25.0%) were affected most. At diagnosis, most had local (83.9%) and regional nodal involvement (12.9%). Mean follow-up was 9.4 years.Mean Breslow depth was 3.1 mm. Amputations were most commonly performed on the thumb at the proximal phalanx or metacarpophalangeal joint (43.9%), and on the hallux at the proximal phalanx or metatarsophalangeal joint (69.0%).Disease progression occurred in 61 (49.2%) patients, and most commonly occurred as regional nodal (62.3%) and distant metastasis (42.6%). Disease progression-free survival rates at 5, 10, and 15 years were 57.1%, 49.9%, and 47.0%, respectively. Fifty-three patients died of melanoma-related causes. Disease-specific survival rates at 5, 10, and 15 years after surgery were 59.3%, 49.3%, and 45.2%. Overall survival rates at 5, 10, and 15 years were 60.5%, 43.8%, and 33.1%.In 116 patients who underwent amputation, resection level outcome analysis with univariate and multivariate analysis adjusting for tumor depth and clinical involvement demonstrated that level of resection was not significantly associated with progression-free, overall, or disease-specific survival. CONCLUSIONS: Diagnosis of subungual melanoma is often delayed and carries a poor prognosis. Conservative resections are warranted as resection level does not influence outcome when histologically free margins are obtained. Amputation through the proximal phalanx or the metatarsophalangeal joint is required in the hallux and toes. Fingers require resection through the distal interphalangeal joint. For the thumb, although resection through the interphalangeal joint proved adequate, secondary efforts should be directed toward maximizing function and quality of life. Function-preserving resections in the thumb with nail removal, partial distal phalanx resection, and volar flap reconstruction are easily performed and preserve length, maximize joint and sensory function, and improve cosmesis.

Original languageEnglish (US)
Pages (from-to)346-354
Number of pages9
JournalAnnals of Plastic Surgery
Volume71
Issue number4
DOIs
StatePublished - Oct 2013

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Thumb
Melanoma
Hallux
Amputation
Metatarsophalangeal Joint
Survival Rate
Joints
Disease-Free Survival
Disease Progression
Metacarpophalangeal Joint
Toes
Nails
Fingers
Registries
Foot
Neoplasms
Multivariate Analysis
Hand
Quality of Life
Neoplasm Metastasis

Keywords

  • Amputation
  • Breslow
  • Cancer
  • Conservative
  • Cutaneous
  • Finger
  • Functional
  • Hand
  • Joint
  • Melanoma
  • Melanotic whitlow
  • Metastatic
  • Nail
  • Pigmentation
  • Subungual
  • Subungual melanoma
  • Surgical management
  • Survival
  • Toe

ASJC Scopus subject areas

  • Surgery
  • Medicine(all)

Cite this

Surgical management of subungual melanoma : Mayo Clinic experience of 124 cases. / Nguyen, Jesse T.; Bakri, Karim; Nguyen, Emily C.; Johnson, Craig H.; Moran, Steven Lawrence.

In: Annals of Plastic Surgery, Vol. 71, No. 4, 10.2013, p. 346-354.

Research output: Contribution to journalArticle

Nguyen, Jesse T. ; Bakri, Karim ; Nguyen, Emily C. ; Johnson, Craig H. ; Moran, Steven Lawrence. / Surgical management of subungual melanoma : Mayo Clinic experience of 124 cases. In: Annals of Plastic Surgery. 2013 ; Vol. 71, No. 4. pp. 346-354.
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title = "Surgical management of subungual melanoma: Mayo Clinic experience of 124 cases",
abstract = "BACKGROUND: Optimal surgical management of subungual malignant melanoma (SMM) has been debated. METHODS: Our tumor registry was reviewed for surgically treated cases of SMM from 1914 to 2010. Resection levels were compared with outcome. RESULTS: During a 96-year period, 124 cases of SMM were identified (65 men and 59 women). Mean age at diagnosis was 58 years. Mean length of symptoms before diagnosis was 2.2 years. Lesions occurred on the hand (n = 79) and foot (n = 45). The thumb (33.8{\%}) and hallux (25.0{\%}) were affected most. At diagnosis, most had local (83.9{\%}) and regional nodal involvement (12.9{\%}). Mean follow-up was 9.4 years.Mean Breslow depth was 3.1 mm. Amputations were most commonly performed on the thumb at the proximal phalanx or metacarpophalangeal joint (43.9{\%}), and on the hallux at the proximal phalanx or metatarsophalangeal joint (69.0{\%}).Disease progression occurred in 61 (49.2{\%}) patients, and most commonly occurred as regional nodal (62.3{\%}) and distant metastasis (42.6{\%}). Disease progression-free survival rates at 5, 10, and 15 years were 57.1{\%}, 49.9{\%}, and 47.0{\%}, respectively. Fifty-three patients died of melanoma-related causes. Disease-specific survival rates at 5, 10, and 15 years after surgery were 59.3{\%}, 49.3{\%}, and 45.2{\%}. Overall survival rates at 5, 10, and 15 years were 60.5{\%}, 43.8{\%}, and 33.1{\%}.In 116 patients who underwent amputation, resection level outcome analysis with univariate and multivariate analysis adjusting for tumor depth and clinical involvement demonstrated that level of resection was not significantly associated with progression-free, overall, or disease-specific survival. CONCLUSIONS: Diagnosis of subungual melanoma is often delayed and carries a poor prognosis. Conservative resections are warranted as resection level does not influence outcome when histologically free margins are obtained. Amputation through the proximal phalanx or the metatarsophalangeal joint is required in the hallux and toes. Fingers require resection through the distal interphalangeal joint. For the thumb, although resection through the interphalangeal joint proved adequate, secondary efforts should be directed toward maximizing function and quality of life. Function-preserving resections in the thumb with nail removal, partial distal phalanx resection, and volar flap reconstruction are easily performed and preserve length, maximize joint and sensory function, and improve cosmesis.",
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T1 - Surgical management of subungual melanoma

T2 - Mayo Clinic experience of 124 cases

AU - Nguyen, Jesse T.

AU - Bakri, Karim

AU - Nguyen, Emily C.

AU - Johnson, Craig H.

AU - Moran, Steven Lawrence

PY - 2013/10

Y1 - 2013/10

N2 - BACKGROUND: Optimal surgical management of subungual malignant melanoma (SMM) has been debated. METHODS: Our tumor registry was reviewed for surgically treated cases of SMM from 1914 to 2010. Resection levels were compared with outcome. RESULTS: During a 96-year period, 124 cases of SMM were identified (65 men and 59 women). Mean age at diagnosis was 58 years. Mean length of symptoms before diagnosis was 2.2 years. Lesions occurred on the hand (n = 79) and foot (n = 45). The thumb (33.8%) and hallux (25.0%) were affected most. At diagnosis, most had local (83.9%) and regional nodal involvement (12.9%). Mean follow-up was 9.4 years.Mean Breslow depth was 3.1 mm. Amputations were most commonly performed on the thumb at the proximal phalanx or metacarpophalangeal joint (43.9%), and on the hallux at the proximal phalanx or metatarsophalangeal joint (69.0%).Disease progression occurred in 61 (49.2%) patients, and most commonly occurred as regional nodal (62.3%) and distant metastasis (42.6%). Disease progression-free survival rates at 5, 10, and 15 years were 57.1%, 49.9%, and 47.0%, respectively. Fifty-three patients died of melanoma-related causes. Disease-specific survival rates at 5, 10, and 15 years after surgery were 59.3%, 49.3%, and 45.2%. Overall survival rates at 5, 10, and 15 years were 60.5%, 43.8%, and 33.1%.In 116 patients who underwent amputation, resection level outcome analysis with univariate and multivariate analysis adjusting for tumor depth and clinical involvement demonstrated that level of resection was not significantly associated with progression-free, overall, or disease-specific survival. CONCLUSIONS: Diagnosis of subungual melanoma is often delayed and carries a poor prognosis. Conservative resections are warranted as resection level does not influence outcome when histologically free margins are obtained. Amputation through the proximal phalanx or the metatarsophalangeal joint is required in the hallux and toes. Fingers require resection through the distal interphalangeal joint. For the thumb, although resection through the interphalangeal joint proved adequate, secondary efforts should be directed toward maximizing function and quality of life. Function-preserving resections in the thumb with nail removal, partial distal phalanx resection, and volar flap reconstruction are easily performed and preserve length, maximize joint and sensory function, and improve cosmesis.

AB - BACKGROUND: Optimal surgical management of subungual malignant melanoma (SMM) has been debated. METHODS: Our tumor registry was reviewed for surgically treated cases of SMM from 1914 to 2010. Resection levels were compared with outcome. RESULTS: During a 96-year period, 124 cases of SMM were identified (65 men and 59 women). Mean age at diagnosis was 58 years. Mean length of symptoms before diagnosis was 2.2 years. Lesions occurred on the hand (n = 79) and foot (n = 45). The thumb (33.8%) and hallux (25.0%) were affected most. At diagnosis, most had local (83.9%) and regional nodal involvement (12.9%). Mean follow-up was 9.4 years.Mean Breslow depth was 3.1 mm. Amputations were most commonly performed on the thumb at the proximal phalanx or metacarpophalangeal joint (43.9%), and on the hallux at the proximal phalanx or metatarsophalangeal joint (69.0%).Disease progression occurred in 61 (49.2%) patients, and most commonly occurred as regional nodal (62.3%) and distant metastasis (42.6%). Disease progression-free survival rates at 5, 10, and 15 years were 57.1%, 49.9%, and 47.0%, respectively. Fifty-three patients died of melanoma-related causes. Disease-specific survival rates at 5, 10, and 15 years after surgery were 59.3%, 49.3%, and 45.2%. Overall survival rates at 5, 10, and 15 years were 60.5%, 43.8%, and 33.1%.In 116 patients who underwent amputation, resection level outcome analysis with univariate and multivariate analysis adjusting for tumor depth and clinical involvement demonstrated that level of resection was not significantly associated with progression-free, overall, or disease-specific survival. CONCLUSIONS: Diagnosis of subungual melanoma is often delayed and carries a poor prognosis. Conservative resections are warranted as resection level does not influence outcome when histologically free margins are obtained. Amputation through the proximal phalanx or the metatarsophalangeal joint is required in the hallux and toes. Fingers require resection through the distal interphalangeal joint. For the thumb, although resection through the interphalangeal joint proved adequate, secondary efforts should be directed toward maximizing function and quality of life. Function-preserving resections in the thumb with nail removal, partial distal phalanx resection, and volar flap reconstruction are easily performed and preserve length, maximize joint and sensory function, and improve cosmesis.

KW - Amputation

KW - Breslow

KW - Cancer

KW - Conservative

KW - Cutaneous

KW - Finger

KW - Functional

KW - Hand

KW - Joint

KW - Melanoma

KW - Melanotic whitlow

KW - Metastatic

KW - Nail

KW - Pigmentation

KW - Subungual

KW - Subungual melanoma

KW - Surgical management

KW - Survival

KW - Toe

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