Acral lentiginous melanoma mimicking benign disease: The Emory experience

doi:10.1067/mjd.2003.63

Journal of the American Academy of Dermatology

Volume 48, Issue 2, February 2003, Pages 183-188

A portion of these data was presented in poster form at the 19th World Congress of Dermatology, Sydney, Australia, June 1997.

https://doi.org/10.1067/mjd.2003.63 Get rights and content

Abstract

Background: Plantar and subungual melanoma exhibits a higher misdiagnosis rate relative to other anatomic sites. Misdiagnosis and delay in diagnosis are statistically associated with poorer patient outcome. Awareness of atypical presentations of acral melanoma may, thus, be important to decrease misdiagnosis rates and improve patient outcome. Methods: We conducted a retrospective case review of plantar or lower-extremity subungual melanoma performed at Winship Cancer Center, a tertiary care, referral center affiliated with Emory University, between 1985 and 2001. Results: A total of 53 cases of plantar or lower-extremity subungual melanoma were identified. Of 53 cases with a final diagnosis of melanoma, 18 were initially misdiagnosed. Misdiagnoses included wart, callous, fungal disorder, foreign body, crusty lesion, sweat gland condition, blister, nonhealing wound, mole, keratoacanthoma, subungual hematoma, onychomycosis, ingrown toenail, and defective/infected toenail. Of the 18 misdiagnosed cases, 9 were clinically amelanotic. Conclusion: Awareness that amelanotic variants of acral melanoma may assume the morphology of benign hyperkeratotic dermatoses may increase the rate of correct diagnosis and improve patient outcome. (J Am Acad Dermatol 2003;48:183-8.)

Section snippets

Methods

Cases of plantar and lower-extremity subungual melanoma were retrieved from the tumor registry of the Winship Cancer Center for the time period 1985 to 2001, inclusive. The Winship Cancer Center is a tertiary care, referral center affiliated with Emory University School of Medicine. The center subsumes the Emory Melanoma and Pigmented Lesions Center, which provides specialized, multidisciplinary care for patients with melanoma from the standpoints of medical oncology, surgical oncology,

Results

A total of 53 cases of plantar or lower-extremity subungual melanoma were identified during the study period. Of 53 cases with a final diagnosis of melanoma, 18 received a prior clinical diagnosis other than melanoma (Table I).

. Patient and clinical characteristics

Patient No.	Age (y)	Sex	Race	Tumor site	Initial diagnosis	Breslow thickness at diagnosis (mm)	Outcome
1	75	F	Caucasian	Left sole	Callus	2.94	Alive; NED
2	79	F	Caucasian	Right sole	Nonhealing ulcer	6.00	DOD
3	63	F	Caucasian	Right sole	Crusty lesion	1.50	Alive; NED
4	62	M

Discussion

Misdiagnosis and delay in diagnosis are relevant topics in the discussion of a cancer that is eminently curable by conservative operation in its early stages, but associated with extremely poor outcome in advanced states. One retrospective study of 83 patients with acral melanoma reported a 36% clinical misdiagnosis rate³ with increased median tumor thickness (5 vs 1.5 mm), more advanced stage at diagnosis (stage IIIb and IV; 30% vs 5.6%), and lower estimated 5-year survival (15.4% vs 68.9%)

References (19)

D Hudson et al.
Plantar melanoma: results of treatment in three populations
Surgery
(1998)
L Talley et al.
Clinical outcomes of localized melanoma of the foot: a case-control study
J Clin Epidemiol
(1998)
B Cassileth et al.
Patient and physician delay in melanoma diagnosis
J Am Acad Dermatol
(1988)
E McBurney et al.
Melanoma mimicking plantar wart
J Am Acad Dermatol
(1979)
C Sutherland et al.
Acral lentiginous melanoma
Am J Surg
(1993)
S Soong et al.
Predicting survival and recurrence in localized melanoma: a multivariate approach
World J Surg
(1992)
R Reed
Acral lentiginous melanoma
(1976)
S Metzger et al.
Extent and consequences of physician delay in the diagnosis of acral melanoma
Melanoma Res
(1998)
D Bennett et al.
The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanoma of the foot
J Am Coll Surg
(1994)

There are more references available in the full text version of this article.

Cited by (100)

Foot Melanoma Localized to Subungual Toe Location Portends Poorer Prognosis
2023, Journal of Foot and Ankle Surgery
Our group previously reported that melanoma of the foot is associated with advanced disease on diagnosis and decreased survival. Lesions localized to the toe appeared to have the worst outcomes. In this study, we both expanded our study to include a 10-year population of patient with invasive melanoma of the foot and ankle and investigated additional factors associated with prognosis. Between January 2007 and December 2016, 211 patients underwent biopsy diagnosis and surgery for invasive melanoma in the BLANK health care system. Demographic, pathologic, staging, and localization characteristics were studied for overall survival. Lesions were localized to dorsal foot, plantar foot, toe (nonsubungual), and toe (subungual) locations. Multivariable analysis found Breslow depth, ulceration, lymph node involvement, and subungual toe location to be associated with poorer survival. Overall survival rate for foot melanoma was 70.6%. Overall survival for nonsubungual toe melanoma was 60.7%, compared to 53.1% for subungual toe melanoma. Of the subungual melanomas, 37.5% of presented as deep lesions with a Breslow depth >4.0 mm. Subungual melanoma was statistically significant for and found to be an independent prognostic factor associated with poorer survival and advanced disease. Based on the results of this study, there should be a low threshold to biopsy suspicious lesions of the toe and foot with particular attention to be dedicated to subungual lesions.
Vigilance to misleading information is required to avoid delayed diagnosis: Case series of acral melanomas
2021, Annals of Medicine and Surgery
Citation Excerpt :
Sondermann et al. reported the relatively high rate of misdiagnosis (~30%) in ALM [13]. Other reports also showed around 25–33% initial incorrect diagnosis of acral melanoma [16,17], which has also been associated with adverse outcome and prognosis [5,13]. Acral lesions with ulceration are also often misinterpreted as infection origin.
Melanoma is considered a rare cancer among Asians with a wide range of mucocutaneous manifestations. Failure to recognize a lesion as melanoma at first presentation might delay surgery aimed at complete resection. Acral melanoma has been related with the highest rate of misdiagnosis (~30%) causing further delayed diagnosis. Reliability of patient’ history taking in melanoma has not yet been systematically reported.
Two patients visited our oncology clinic with pigmented lesions in their soles. A 66-year-old man disclosed it appeared since a year ago after accidently hitting a stone while farming. Physical examination showed a black-brown irregular 100 × 80 mm lesion covering the distal third of the right sole with ulceration in the central lesion. The second patient was a geriatric woman with a black-purple 25 × 27 mm lesion with slight protrusion and ulceration in the central, irregular border, and partial hyperkeratosis. She explained the lesion emerged two years ago after she accidently stepped on a nail. Both patients were then diagnosed with acral melanomas and were treated with wide-excision, closure with skin grafting, and inguinal dissection.
Both patients reported history of traumas in lesions later confirmed as acral melanomas. Although history taking can provide up to 80% of the information for accurate diagnosis, in ambivalent cases, careful anamnesis, clinical examination, and biopsy are required to confirm diagnosis of acral melanoma. Early disease identification to establish definitive diagnosis of cancer is generally associated with better clinical outcomes. In suspected cases, vigilance toward misleading information in history taking is required.
Does acral lentiginous melanoma subtype account for differences in patterns of care in Black patients?
2021, American Journal of Surgery
Citation Excerpt :
Because acral melanoma occurs subungually, many may confuse ALM for melanonychia, a benign finding of a black or brown line under the nail, which is common within the Black community.8,16,17 Furthermore, the limited education about melanoma within the Black community may further limit early diagnosis8,18 with studies showing that Black patients are less able to identify a worrisome lesion and their physicians are less likely to perform a head to toe examination.8,16,18 This latter point illustrates the possibility that systemic differences in the care provided to Black patients could contribute to the differences in amputation rates.
Melanoma-specific outcomes for Black patients are worse when compared to non-Hispanic white (NHW) patients. We sought to evaluate whether acral lentiginous melanoma, seen more commonly in Black patients, was associated with racial disparities in outcomes
The National Cancer Database was analyzed for major subtypes of stage I-IV melanoma diagnosed from 2004 to 2016. The association between Black race and (Siegel et al., Jan) 1 acral melanoma diagnosis and (Bradford et al., Apr) 2 receipt of major amputation for surgical management of melanoma was evaluated using multivariable logistic regression.
251,864 patients were included (1453 Black). Black patients had increased odds of acral melanoma (odds ratio [OR] = 27.6, 95% CI]: 24.4, 31.2) compared to NHW patients. Black patients still had higher odds ratios of major amputation across all stages after adjusting for acral histology and other potential confounders
Increased prevalence of acral melanoma in Black patients does not fully account for increased receipt of major amputation.
Onychomycosis: Clinical overview and diagnosis
2019, Journal of the American Academy of Dermatology
Citation Excerpt :
However, a biopsy specimen should be obtained from any concerning melanonychia to rule out subungual melanoma. Onychomycosis may coexist with other nail malignancies, and therefore significant nail dystrophy or failure to improve with antifungal therapy, despite laboratory evidence of a fungal infection, should prompt obtaining a biopsy specimen from a nail.59,60 Dermoscopy is a helpful noninvasive diagnostic tool that can be used to differentiate onychomycosis from both traumatic onycholysis and melanonychia.61,62
Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophytes, and yeast, and is the most common nail disorder seen in clinical practice. It is an important problem because it may cause local pain, paresthesias, difficulties performing activities of daily life, and impair social interactions. In this continuing medical education series we review the epidemiology, risk factors, and clinical presentation of onychomycosis and demonstrate current and emerging diagnostic strategies.
Melanoma of the Foot Is Associated With Advanced Disease and Poorer Survival
2018, Journal of Foot and Ankle Surgery
The purpose of the present study was to review the outcomes and assess the prognostic factors associated with foot melanoma. We hypothesized that primary melanoma of the foot would be more likely to present at an advanced stage and be associated with poorer outcomes. Both univariate and multivariate analyses were conducted to examine the relationships between patients' demographic, clinical, and pathologic characteristics and deaths within 5 years. Categorical data were summarized as frequencies and percentages and continuous variables as mean ± standard deviation. The primary outcome measure was overall survival. On univariate analysis, the significant prognostic variables found included Breslow thickness, ulceration, sentinel node positivity, and localized presentation on the toe. Age, sex, and race were not prognostically significant in this model. Multivariate Cox proportional hazards analysis resulted in a model of foot melanoma with ulceration and location on the toe as independent prognostic variables. The 5-year survival rate for melanoma of the toe was 50%. The results of the present study have shown that physicians should have a low threshold to biopsy suspicious lesions of the foot and ankle. Advanced disease and poorer survival were noted with toe melanoma. An ulcerative lesion of the foot was also associated with poorer survival.
Acral Melanoma Incidence and Survival Trends in Sweden: Insights from a Population-Based Study 1990–2020
2023, SSRN

View all citing articles on Scopus

^☆: Funding sources: None.

^☆☆: Conflict of interest: None identified.

^★: Reprint requests: Carl V. Washington, MD, Emory University School of Medicine, Department of Dermatology, 5001 Woodruff Memorial Bldg, Atlanta, GA 30322. E-mail: [email protected].

^★★: 0190-9622/2003/$30.00 + 0

View full text

ReportsAcral lentiginous melanoma mimicking benign disease: The Emory experience☆,☆☆,★,★★

Abstract

Section snippets

Methods

Results

Discussion

Surgery

J Clin Epidemiol

J Am Acad Dermatol

J Am Acad Dermatol

Am J Surg

Predicting survival and recurrence in localized melanoma: a multivariate approach

World J Surg

Acral lentiginous melanoma

Extent and consequences of physician delay in the diagnosis of acral melanoma

Melanoma Res

The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanoma of the foot

J Am Coll Surg

Reports
Acral lentiginous melanoma mimicking benign disease: The Emory experience☆,☆☆,★,★★