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Subungual Melanoma: A Search for an Evidence-Based Treatment Plan
Abigail Maciolek Cochran, MD1; Patrick J. Buchannan, MD2; Reuben A., Jr. Bueno, MD1; Michael W. Neumeister, MD1
1Institute of Plastic Surgery, Southern Illinois University, Springfield, IL; 2Department of Plastic surgery, University of Michigan, Ann Arbor, MI

Introduction: Subungual melanoma has historically been associated with a poor prognosis as a result of its frequent misdiagnosis and advanced disease on presentation. Amputation was felt to be the best means of preventing recurrence and deadly metatstasis, though; this was never based on scientific evidence. While cutaneous melanoma treatment has trended towards more conservative resections, aggressive amputation for subungual melanoma persists. In recent years, however, this dogma of amputating the digit involved with subungual melanoma has been challenged making the proper surgical treatment somewhat controversial.

Methods: A comprehensive review of the current literature regarding treatment and outcomes of subungual melanoma was undertaken. Surgical treatment was broken down into two groups: wide local excision (WLE) and amputation. Depth of lesion, previous treatment, stage of disease at presentation, adjunct therapy, local and distant recurrence, and survival were evaluated for the respective treatment groups. Direct comparison was performed to gain a better understanding of surgical trends, and to draw conclusions about the respective outcomes.

Results: Eight-hundred eighty-three cases of surgically treated subungual melanoma were analyzed. Eighty-six (9.8%) of the cases were treated with WLE and 69 of these (80.2%) had a defined depth of lesion on presentation. Conversely, 797 cases (90.2%) were treated by amputation of some kind; 705 (88.4%) of which were lacking a defined depth on presentation. In the amputation group, 11.4% presented with advanced disease (regional or distant recurrence), compared to 2.3% in the WLE group. Local recurrence rate for WLE and amputation were 11.6% and 5.8% respectively; regional/distant metastasis was comparable at 13.9% and 13.4%.

Conclusion: In the majority of articles, conclusions cannot be drawn due to a lack of comparable treatment groups, the strong presence of biases, and numerous co-founding factors. As a result, and based on this review, it seems as though amputation at the next joint level may be unwarranted, and WLE is justifiable. Among patients presenting with MIS, it is safe to perform a wide local excision with close follow up. The literature is in need of randomized, prospective, or comparative studies that would help elucidate whether amputation is superior to a more conservative, digit-sparing, approach.

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