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Valdes Morales KL, Frankel D, Trifoi MD, Lin SK, Deitermann AM, Lubeck M, Sobanko JF, Higgins HW, Giordano CN, Walker JL, Zhang J, Lewis DJ, Chang B, Wink JD, Lin IC, Kovach SJ, Etzkorn JR, Miller CJ. Nail unit melanoma treated with Mohs micrographic surgery: Technique, local recurrence rate, and surgical outcomes. J Am Acad Dermatol 2025; 92:1072-1079. [PMID: 39848587 DOI: 10.1016/j.jaad.2024.11.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 10/09/2024] [Accepted: 11/12/2024] [Indexed: 01/25/2025]
Abstract
BACKGROUND Nail unit melanoma (NUM) is increasingly treated with digit-sparing surgery, but few published case series describe Mohs micrographic surgery (MMS) for NUM. OBJECTIVE To describe the surgical technique, local recurrence rates, and reconstruction method for a large series of NUM treated with MMS using melanoma antigen recognized by T cells-1 immunostaining. METHODS Biopsy-proven NUM treated with MMS-melanoma antigen recognized by T cells-1 were identified from a prospectively maintained database (2008-2023). Primary outcome was local recurrence rate. Secondary outcomes included rate of subclinical spread and rate of ablative versus reconstructive amputation. RESULTS Sixty-nine NUM were identified, including 51 melanomas in situ (73.9%) and 18 invasive melanomas (26.1%) with mean Breslow thickness of 1.07 mm (range 0.2-5.4 mm). One local recurrence (1/69, 1.4%) occurred during a mean follow-up time of 38.2 months. Subclinical spread (>1 Mohs stage) was common (38/69, 55.1%). Amputation was rarely necessary to clear the melanoma (5/69, 7.2%), but amputation at different levels was performed to reconstruct 33 cases (33/69, 47.8%) with extensive exposed bone. LIMITATIONS Single center cohort and lack of patient-reported outcomes. CONCLUSION MMS treats NUM with low local recurrence rates. Amputation is rarely necessary to obtain clear tumor margins, but it may be necessary or desirable to reconstruct MMS defects with extensive exposed bone.
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Affiliation(s)
- Karla L Valdes Morales
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniela Frankel
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Mara D Trifoi
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Stephanie K Lin
- Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | | | - Marissa Lubeck
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - H William Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cerrene N Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joanna L Walker
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Junqian Zhang
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J Lewis
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Chang
- Department of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Wink
- Department of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ines C Lin
- Department of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Department of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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Le M, Gabrielli S, Zloty D. Mohs Micrographic Surgery Is Equivalent to Nail Unit Excision or Amputation for Melanoma In Situ of the Nail Unit: A Systematic Review and Meta-Analysis. Dermatol Surg 2023; 49:755-758. [PMID: 37249515 DOI: 10.1097/dss.0000000000003840] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Local recurrence (LR) rates of melanoma in situ (MIS) of the nail apparatus treated with different surgical modalities are unknown. OBJECTIVE To evaluate the differences in LR rates of nail apparatus MIS treated with Mohs micrographic surgery (MMS) versus nail unit excision (NUE) versus amputation. METHODS Studies of nail/subungual MIS treated with MMS, NUE, or amputation were identified through multiple literature databases, including PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library. Pooled data were assessed through meta-analyses and Fisher exact test. RESULTS Of 280 studies identified, 20 met inclusion criteria (7 comparative studies and 13 single-arm studies). Among the 7 comparative studies, the LR was 4.38% (5/114) after NUE and 2.94% (1/34) after amputation (odds ratio: 0.937; 95% CI: 0.237-3.703). In the 13 noncomparative studies, 23 patients underwent MMS (pooled LR estimate: 11.07%; 95% CI: 3.22%-31.81%) and 140 patients underwent NUE (pooled LR estimate:8.04%, 95% CI: 4.43%-14.16%). The difference in LR rate between MMS, NUE, and amputation was not statistically significant ( p = .578). CONCLUSION Local recurrence of nail/subungual MIS in cases treated with MMS was not statistically different than in cases treated with NUE and was comparable to amputation. Further studies investigating the use of MMS for the treatment of nail/subungual MIS are warranted.
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Affiliation(s)
- Michelle Le
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sofianne Gabrielli
- Division of Dermatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - David Zloty
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada
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Hwang JK, Lipner SR. Blue Nail Discoloration: Literature Review and Diagnostic Algorithms. Am J Clin Dermatol 2023; 24:419-441. [PMID: 36971947 DOI: 10.1007/s40257-023-00768-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/29/2023]
Abstract
Blue nail discoloration is a distinctive clinical presentation, and diagnosis is challenging given the broad differential diagnosis. A comprehensive review of the literature describing blue discoloration of one or multiple nails was performed using the PubMed, Embase, Scopus, and Web of Science databases. A total of 245 publications were included and grouped based on involvement of a single nail (monodactylic) or multiple nails (polydactylic). Monodactylic blue discoloration was associated with tumors or benign nevi, most commonly glomus tumors, followed by blue nevi and less commonly melanomas. Polydactylic blue discoloration was frequently associated with medications (such as minocycline, zidovudine, and hydroxyurea), toxic and exogenous exposures (such as silver), and other medical conditions (such as HIV/AIDS and systemic lupus erythematous). Patients presenting with blue nail discoloration warrant a thorough history, physical examination, and workup to rule out malignancy, systemic disease, or toxic exposure. We present diagnostic algorithms for monodactylic and polydactylic blue nail discoloration to guide workup and treatment plans.
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Lambertini M, Piraccini BM, Fanti PA, Dika E. Mohs micrographic surgery for nail unit tumours: an update and a critical review of the literature. J Eur Acad Dermatol Venereol 2018; 32:1638-1644. [PMID: 29706031 DOI: 10.1111/jdv.15036] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/29/2018] [Indexed: 02/03/2023]
Abstract
Mohs micrographic surgery (MMS) is a good treatment option for epithelial neoplasms, especially when localized in areas where tissue conservation is crucial, such as the nail unit (NU). MMS is a method of radical excision offering high cure rates due to the margin control and functional preservation. Our aim is to provide a review on the use of MMS for the treatment of the most common nail tumours. We revised the current literature on the use of MMS to treat malignant neoplasms (Bowen's disease, squamous cell carcinoma, melanoma, basal cell carcinoma, keratoacanthoma, carcinoma cuniculatum) and benign neoplasms (onychomatricoma and glomus tumour). MMS represents a successful surgical option for nail tumours, firstly in terms of tissue conservation: the NU anatomy is complex and the preservation of the component structures is imperative for its functionality. Secondly, due to the surgical radicality, which is essential not only for the clearing of malignant tumours, but also for benign cases, in order to reduce recurrences. Although a conservative treatment of NU melanoma with MMS has been proposed, in our experience, the conservative approach with functional surgery is a good option for the treatment of non-invasive melanoma (in situ and Ia).
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Affiliation(s)
- M Lambertini
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - B M Piraccini
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - P A Fanti
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - E Dika
- Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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Piraccini BM, Dika E, Fanti PA. Tips for diagnosis and treatment of nail pigmentation with practical algorithm. Dermatol Clin 2015; 33:185-95. [PMID: 25828711 DOI: 10.1016/j.det.2014.12.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The observation of a black-brown pigmentation of the nail is often alarming for the patient and for the clinician, as they are aware that it can be a possible clinical manifestation of melanoma of the nail apparatus. Luckily, however, nail melanoma is a much less frequent cause of brown-black nail color than other melanocytic and nonmelanocytic pigmentations, which include subungual hematoma, exogenous pigmentations, and melanonychia due to benign conditions. A correct clinical history and careful examination help the clinician to distinguish the different conditions and to decide the correct management of melanonychia both in children and in adults.
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Affiliation(s)
- Bianca Maria Piraccini
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 1, Bologna 40138, Italy.
| | - Emi Dika
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 1, Bologna 40138, Italy
| | - Pier Alessandro Fanti
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 1, Bologna 40138, Italy
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