Hand Surgery Source

MELANOMA

Introduction

Cutaneous melanoma is the most common type of melanoma; however, melanomas of the hand are rare (2%) and typically occur as finger or thumb-tip lesions. Overall survival for hand melanoma is good, at ~70%. Survival is decreased in patients with subungual melanoma, likely due to diagnostic delay. The main environmental risk factor for cutaneous melanoma is ultraviolet radiation from sun exposure and tanning beds. The risk is more strongly associated with intermittent exposure to high-intensity sunlight, which leads to sunburn which increases the risk of melanoma. Heredity may be a factor in some families. 3,4 Immunosuppressed patient's are at higher risk. Early and accurate diagnosis and treatment of melanocytic lesions is critical, but difficult. Melanoma of the hand requires special attention because the skin of the hand is structurally unique to allow for fine sensibility, mobility for complex motor skills, and durability.1,2

Melanoma is classified by the Clark level and the Breslow thickness. The Clark level is defined by the depth of the melanoma cells in the dermis. The Breslow thickness guides therapy and is a measurement of thickness of the melanoma cells on biopsy.

Pathophysiology

  • Cutaneous melanoma cells spread out within the epidermis (radial growth phase).
  • When they reach the dermis, they can spread to other tissues via the lymphatic system to the local lymph nodes, or via the blood stream to other organs (vertical growth phase).
  • There are four types of melanoma
    1. Lentigo malignant
    2. Superficial spreading
    3. Nodular
    4. Acral lentiginous
      1. Occurs in Blacks and Asians
      2. 1-3 spread horizontally and is curable if treated early

Incidence and Related Conditions

  • 2% of melanomas occur in the hand.
  • Worldwide, malignant melanoma accounts for 1% of all cancer deaths but for 80% of all skin cancer deaths
  • Incidence rates in the United States have increased 200% since 1973; similar increases in the UK, especially in white men aged >60 years. Increases are more rapid than for any other cancer type
  • Incidence is higher in women aged <50 years; twice as high in men by age 65. By age 80, rates in men are triple those in women.
  • Mortality rate is higher in men (4.8 vs 2.8 deaths per 100,000).
  • The incidence of melanoma is greater in the white population.

Differential Diagnosis

  • Angiokeratoma (angioma)
  • Blue nevus (precursor of melanoma)
  • Nevus
  • Dermatofibroma
  • Hemangioma
  • Actinic lentigo
  • Pigmented actinic keratosis
  • Pigmented basal cell carcinoma
  • Seborrheic keratosis
  • Traumatic hematoma
  • Traumatized or irritated nevus
  • Pyogenic granuloma
ICD-10 Codes

MELANOMA

Diagnostic Guide Name

MELANOMA

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
MELANOMA   C43.62 C43.61  

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Clinical Photos Melanoma
  • Melanoma subungual left long finger. Originally this patient presented as a chronic "infection" and a mass consistent with a subungual granuloma. Silver nitrate cauterization did not resolve the problem. The lesion and black residue from the silver nitrate was excised. Diagnosis of melanoma was made. Photo shows left long finger after sentinel node injection and before amputation. Note pigmented tissue arrow.
    Melanoma subungual left long finger. Originally this patient presented as a chronic "infection" and a mass consistent with a subungual granuloma. Silver nitrate cauterization did not resolve the problem. The lesion and black residue from the silver nitrate was excised. Diagnosis of melanoma was made. Photo shows left long finger after sentinel node injection and before amputation. Note pigmented tissue arrow.
  • Melanoma right anterior axilla (arrow)
    Melanoma right anterior axilla (arrow)
  • Melanoma right index fingertip (arrow)
    Melanoma right index fingertip (arrow)
Basic Science Photos and Related Diagrams
Clark's Level and Breslow Thickness
  • Clark's level is determined by the depth of the melanoma cells in the dermis. Breslow thickness measures the thickness of the lesion in the skin which defines the surgical margins and helps predict the five year survival rate. (references 3-8).
    Clark's level is determined by the depth of the melanoma cells in the dermis. Breslow thickness measures the thickness of the lesion in the skin which defines the surgical margins and helps predict the five year survival rate. (references 3-8).
Symptoms
Pigmented skin lesion
Pruritus, ulceration, and bleeding in a mole
Moles that are asymmetric, have irregular borders, have variability or recent change in color, and are >6 mm in diameter
Any one symptom can be a warning sign
Typical History

The typical patient will have red or blonde hair, blue or green eyes, and fair skin with low tanning ability. The patient’s skin will feature freckles and multiple melanocytic nevi (≥100) or ≥5 atypical nevi, and there may be a family history of melanoma (10% of cases). The initial complaint is likely to be a mole with changed appearance, or other skin marking. The "ugly duckling" mole should always be considered for biopsy. Primary melanomas on the fingers tend to occur in older patients (mean age, 60 y). The primary melanoma is rarely on the palm. On questioning, the patient may describe tanning bed use and a history of sunburns. 

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Melanoma Imaging Studies
  • Normal X-ray left long finger from patient with a subungual melanoma.
    Normal X-ray left long finger from patient with a subungual melanoma.
  • Imaging after injection for a sentinel node biopsy of patient with a subungual melanoma left long finger. Note uptake in left axilla.
    Imaging after injection for a sentinel node biopsy of patient with a subungual melanoma left long finger. Note uptake in left axilla.
Treatment Options
Conservative

-  The primary treatment of melanoma is surgical excision or amputation

  • Topical imiquimod can be used for in situ disease in elderly who have poor anesthetic risks.
Operative

Amputations are unnecessary. Lesser digital amputations are acceptable when the tumor is treated early enough to allow an adequate margin. In a chart review of 39 patients with melanoma of the hand, local treatment consisted of wide excision, finger amputation, or ray amputation. Local treatment was often combined with lymph node dissection.

  • In a chart review of 27 patients diagnosed with malignant melanoma of the hand (13 on thumb tip, 13 on fingertip), amputa­tion was most frequently used, followed by skin graft, venous free flap, and free flap.
  • Since 2009, tissue-sparing excision and re­construction with venous free flap has been performed most frequently.
  • Elective lymph node dissection in patients with cutaneous melanoma is no longer recommended. However, 5-year survival increases with sentinel lymph node biopsy.

Sentinel node biopsy is indicated for lesions ≥1.0mm thickness or ulcerated lesions. Skin lesions should be excised with an adequate margin determined by the depth of invasion and thickness.

  • Sentinel node biopsy procedure - A radioactive tracer and blue dye are injected at the melanoma site. A nuclear medicine scanner then identifies the sentinel lymph node in the axilla. The axilla dissection is then done. A gamma probe and the dye is used to identify the node to biopsy. A positive node biopsy determines the prognosis and treatment plan.

Surgical Margins for Melanoma

Tumor Thickness

Horizontal Surgical Margins

Melanoma in situ (confined to epidermis)

5 mm

< 1 mm

1 cm

1.0-2.0 mm

1-2 cm

2.0-4.0 mm

>2 cm

> 4 mm

>4 cm

 

Metastatic disease - In the past, intravenous dacarbazine has been the principle cytotoxic chemotherapy for melanoma for >20 years.

  • Immunotherapy is now the primary adjunct therapy for melanoma
  • Treatment options for metastatic disease now include novel therapies such as BRAF and MEK inhibitors and immunomodulatory checkpoint inhibitors (eg, ipilimumab, nivolumab, pembrolizumab). Interleukin 2 and an oncolytic virus were recently approved by the FDA for the treatment of melanoma.1,2,4

Radiotherapy to reduce the recurrence risk or treat recurrence or radioembolization.

Treatment Photos and Diagrams
Surgical Treatment for Melanoma
  • Left long finger after amputation for subungual melanoma
    Left long finger after amputation for subungual melanoma
  • Healed left long finger after amputation for subungual melanoma
    Healed left long finger after amputation for subungual melanoma
CPT Codes for Treatment Options

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CPT Code References

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Complications

SURGICAL COMPLICATIONS

  • Incomplete excision
  • Lymphoedema  
  • Nerve injury
  • Wound infection
  • Recurrence
  • Metastatic disease
  • Death
Outcomes
  • Local excision of malignant melanoma: treatment failure in ~45% of patients
  • Only 25% of patients with metastases in lymph nodes survive 5 years from primary surgery
Key Educational Points
  • ABCD rule: suspicious lesions are characterized by ­asymmetry, border irregularities, color heterogeneity, dynamics, (dynamics or evolution in colors, elevation or size). This rule does not apply to subungual melanoma 1-4
  • Visual inspection should focus on lesions that do not fit the patient’s nevus pattern
  • Diagnosis is based on a full-thickness biopsy
  • Follow-up is important and depends on the cancer stage. Advice about self-examination should be reinforced at each follow-up appointment.
  • Any pigmented lesion of the hand must be diagnosed. If it does not resolve promptly, perform a biopsy.
  • During the past decade, the strategy for hand melanoma has changed from radical surgery, including ray amputation, to more conservative treat­ment when possible, but wide excision and digital amputations remain the main stay of melanoma treatment .
References

New Articles

  1. Yun MJ, Park JU, Kwon ST. Surgical options for malignant skin tumors of the hand. Arch Plast Surg 2013;40(3):238-43. PMID: 23730600
  2. Martin DE, English JC, Goitz RJ.  Subungual malignant melanoma. J Hand Surg Am 2011;36:704-07. PMID: 21277700
  3. English C, Hammert WC. Cutaneous malignancies of the upper extremity. J Hand Surg Am 2012;37(2):367-77. PMID: 22281171
  4. Marks JG, Miller, JJ. (2013). Chapter 4. Lockingbill and Mark's Principles of Dermatology Fifth Edition. Chapter 6 Pigmented Growths. pp 60-71. Saunders Elsevier. London, New York
  5. Sladden MJ, Blach C, Barzilai DA, Berg D, Freiman A, Handiside T, et al. Surgical excision margins for primary cutaneous melanoma. Cochrane Database Syst Rev 2009; Oct 7:CD004835.
  6. Clark WH Jr, Elder DE, Guerry D IV, Epstein MN, Greene MH, Van Horn M. Hum Pathol 1984;15:1147-1165.
  7. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Annal Surg 1970;172:902-908.
  8. Clark WH Jr, From L, Bernardino EA, Mihm MC. The histogenesis and biologic behavior of primary human malignant melanoma of the skin. Cancer Res 1969;29:705-727.

Reviews

  1. Ilyas EN, Leinberry CF, Ilyas AM. Skin cancers of the hand and upper extremity. J Hand Surg Am 2012;37(1):171-8. PMID: 22196297

Classic

  1. Kerin R. The hand in metastatic disease. J Hand Surg Am 1987;12(1):77-83. PMID: 3543107