Thumb subungual melanoma: Is amputation necessary?

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Summary

Subungual melanoma is uncommon. Traditional teaching advocates amputation of the affected digit. Recent studies have shown that more distal levels of amputations do not compromise survival or recurrence rates. When the thumb is involved, functional and aesthetic loss can be substantial. We present a new conservative, digit-sparing approach in the treatment of subungual melanoma of the thumb. Four informed patients were recruited to undergo the new treatment. Local excision with 1 cm margins down to and including the periosteum was carried out. Reconstruction was with a local flap. There has been one recurrence and no deaths with a minimum of 6 years follow up. In selected cases, conservative management of subungual melanoma allows preservation of length and minimises disability.

Section snippets

Method

Four patients with subungual melanoma of the thumb were treated. They had all requested conservative management in the case of the second patient, this was due to physical disability and care of her colostomy which was a result of surgery for Crohn's disease. They were fully informed as to the unconventional nature of the surgery. All had initial biopsies to confirm the diagnosis. The tumour was excised down to and including the periosteum, and paratenon where appropriate, with a 1 cm peripheral

Results

Four cases of thumb melanoma were treated (Table 1). The mean age of the patients was 56 years (range 50–74) with Breslow thickness ranging from 0.9 to 4 mm. Mean follow up was 94 months (range 77–117). In all cases length has been maintained. One patient had a local recurrence at 36 months and proceeded to an amputation at mid-proximal phalynx level. She remained disease free, but died of unrelated causes at 88 months follow up. The other patients remain disease free.

Discussion

Historically, wide local excision has been advocated for cutaneous melanoma. The exact origin of this dictate is unclear but it is probably from anatomical studies by Handley.7 Digital amputation in treatment of subungual melanoma probably came from Hutchinson's original description of the condition in 1886.8 A recent prospective study has shown that narrower margins are oncologically safe.9 A number of studies on subungual melanoma have shown that more distal amputations do not compromise

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This paper was presented at the British Association of Plastic Surgeons Summer Meeting 2004.

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