American Association for Hand Surgery
Theme: Beyond Innovation

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Acral Lentiginous Melanoma: Does Surgical Approach Matter?
Marc E. Walker, MD, MBA1; Alex Sun, MD2; Kyle Gabrick, MD3; Jack Kanouzi, MD4; Gang Han, PhD5; Ying-Chun Lo, MD6; Anjela Galan, MD6; James E Clune, MD7; Deepak Narayan, MBBS, FRCS7; Stephan Ariyan, MD7; Dale Han, MD8
1Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, 2Yale University, Section of Plastic Surgery, New Haven, CT, 3Section of Plastic and Reconstructive Surgery, Yale University School of Medicine,, New Haven, CT, 4Yale University School of Medicine, New Haven, CT, 5Texas A&M University, College Station, TX, 6Yale University Department of Pathlogy, New Haven, CT, 7Yale University, New Haven, CT, 8Yale University Surgical Oncology, New Haven, CT

Introduction
Acral lentiginous melanoma (ALM) is a specific type of malignant melanoma found on the palms, soles, and under the nails. Comprising approximately 1-3% of all melanoma, ALM is an unusual malignancy with poor survival and is the most common form of skin cancer affecting African-Americans and Asians. Excision of melanoma of the toe or finger remains controversial. The traditional method of treatment is amputation of the involved digit. The thumb is the most commonly affected digit in the hand, and loss of its function can be devastating. This study aims to determine if surgical approach matters for local recurrence and survival in acral melanoma patients.
Methods
In this IRB-approved study, we performed a retrospective review using the prospectively maintained Yale Dermatopathology Database for all patients with a diagnosis of ALM during 1998-2017 using the search terms acral-lentiginous, acral lentiginous, acrolentiginous, melanoma + nail, palm, sole, periungual, subungual, finger, and toe. A total of 48 patients were identified with diagnosis of ALM after exclusion of in situ-only lesions. Descriptive statistics including mean, median, standard deviation, IQR, frequency, and percentage were reported for demographic variables in all ALM patients who underwent surgery and lymph node dissection (LND). Logistic regression and cox proportional hazard regression analysis were applied to identify significant predictors for sentinel node positivity and patient overall survival, respectively.
Results
Statistical analysis revealed no significant difference in patient demographics, risk factors, nor tumor characteristics. 31 patients had ALM of the foot and 12 on the hand (p=0.01). 75% (9/12) and 39% (12/31) of patients with foot and hand lesions, respectively, underwent total digit amputation, and all remaining patients underwent local excision with standard margins. Tumor location, thickness, axillary node site, and undergoing lymphadenectomy all were shown to be significantly associated with surgical approach (p=>0.05). There was no statistically significant difference in local recurrence between the two groups. Amputation was not found to be associated with increased survival compared to wide local excision/digit-sparing surgery.
Conclusions
Given the significant morbidity and loss of function associated with total digit amputation, careful consideration must be taken when deciding surgical approach for melanoma of the fingers and toes. In this review of 48 patients with acral lentiginous melanoma, we have shown that there is no difference in local recurrence and no survival benefit of amputation versus wide local excision.


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