Melanotic Tumors of The Hand--P. Banzet, J. Glicemstein and C. Dufourmental
MELANOTIC TUMOURS OF THE HAND P. B A N Z E T , J. G L I C E N S T E I N and C. D U F O U R M E N T E L , Paris There are two main problems concerning melanotic tumours of the hand. First, the diagnosis, which is often fairly difficult to make, particularly for malignant types. The second problem is their treatment, completely different for benign and malignant tumours. PROBLEMS OF DIAGNOSIS Melanotic tumours of the hand are lesions of widely varying significance. Some naevi appear safe, and definitely benign. Small pigmented turnouts often arise on the hand or the digits as they do in every other skin area. The dorsum of the hand is also a well known site for blue naevi. Although its dark colour m a y frighten, such a lesion will very rarely become malignant. It should be regarded normally as benign. Giant hairy and pigmented naevi may also involve the hand. They often also cover a large part of the forearm. Of course, m a n y years later a malignant melanoma could occur. But in fact, their surgical removal is often requested for aesthetic reasons earlier. T h e extensive verrucous naevus can sometimes lead to a squamous cell carcinoma. This would be a reason to propose prophylactic surgery, but, here also, the aesthetic problem is often sufficient reason for the patient to request excision of his lesion at an early date. There is a very high risk of subsequent malignancy, in some naevi which are at first benign. These are s u b u n g u a l n a e v i . They appear as a pigmented band, lying on the nail bed, involving its whole length, the matrix, and even the nail wall and fold. Discovering such a lesion early is very important, as, m a n y pathologists believe that it will eventually become malignant melanoma. Of course, one can mistake m a n y other lesions for malignancy, such as subungual benign papilloma, subungual foreign bodies, subungual glomus tumours, or even the c o m m o n subungual haematoma. But, if there is any doubt about the nature of a subungual pigmented naevus, one-block excision biopsy of the whole lesion is mandatory, followed by careful histopathology. The development of frank malignancy in these lesions is often a long delayed process; one could believe that it is a type of superficial spreading m e l a n o m a with secondary development of a nodular tumour. If so, the earlier the surgery, the safer it should be. Malignant m e l a n o m a can present in various ways on the hand It m a y look like typical skin m e l a n o m a in one of the various types, wellknown and described by Clark (1969) as superl~cial spreading or nodular melanoma. It can also be amelanotic. It can also develop in Hutchinson's Freckle; this is not as c o m m o n on the hand, but all these should be detected early and rather easily. F a r more difficult is the problem of the melanotic whitlow and the nail is the commonest site for m e l a n o m a on the hand. At first, it is very hard to detect the malignancy; discovering a little inflammatory halo around the nail base could raise suspicion but the only certain sign is an involvement of the nail; it is then already pretty late in the development of the lesion. Diagnosis is easier when the naevocarcinoma appears not only on the nail bed but also .around the nail base, or on the side of the nail, or the finger tip. The Hand--Vol. 7
No. 2
1975
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Melanotic Tumors of The HandnP. Banzet, J. Glicemstein and C. Dufourmental
Even so, such a lesion is too often neglected. Often, an injury is related. In other cases, it looks like a chronic infection with a granuloma persisting for months and months. According to our records in Saint Louis Hospital, Paris, we have to treat 7 5 % of our patients after delays varying f r o m a few months to two years, and this seems to prejudice the outcome for our patients greatly. Even under such conditions however, our overall survival rate for melanotic whitlow stands at 35°/° at five years. The h a n d is not the worst site for malignant m e l a n o m a and we think that an early diagnosis should greatly improve the survival rate. We believe that focussing attention on this aspect is the main purpose of writing about melanotic tumours of the hand. TREATMENT
Benign naevi provide a typical field for plastic hand surgery. All surface naevi can be removed, and the wound closed by direct suture, or sometimes covered by secondary healing. The extensive types will require wide excision. Cover will sometimes be possible by rotation flaps, but more often will need skin grafts; full thickness skin on the volar side, split skin on the dorsum. The classical rules about choosing a safe position and good orientation for the scars in order to avoid contraction and preserve function are of course of the greatest importance. F o r Malignant m e l a n o m a we believe that the problem is completely different. Such a lesion can require a multidisciplinary approach where the surgical stage is not the most important. Of course, ablative surgery is still one of the basic steos but chemotherapy and i m m u n o t h e r a p y have also to be harmoniously included. Removing malignant melanoma lying in the skin covering the hand is straightforward, and a wide excision is possible without severe functional defect. But on the digits and for melanotic whitlow the only possibility is to perform an amputation. Even so, according to the anatomical conditions, the excision will not be very wide. As such an amputation on the thumb is necessarily restricted we believe that one is justified in including surgery in a combined treatment, to try to minimise the extent of the resection and thus salvage some important elements of function. Such a conservative attitude does not seem, according to our own statistics, to have any significant effect on the anticipated survival rate and improves greatly the residual hand function of the patient. The wideness of the excision does not appear to be an overwhelming factor influencing prognosis at this site in a combined therapeutic approach. REFERENCES
CLARKE, W. H., FROM, L., BERNARDINO, E. A., and MIHM, M.C. (1969) The Histogenesis and Biologic Behavior of Primary Human Malignant Melanomas of the Skin. Cancer Research, 29: 705-726. DUFOURMENTEL, C., MOULY, R., BANZET, P., PREAUX, J., and GLICENSTEIN, J. (1968) Le Panaris M61anique: M61anome malins sous et p6ri ungu6al. Apropos de 22 cas. Memoires de l'Acad6mie de Chirurgie 94: 309-314. LEPPARD, B., SANDERSON, K. V. and BEHAN, F. (1974) Subungual Malignant Melanoma: Difficulty in Diagnosis. British Medical Journal, 1:310-312. LUCE, J. K., (1972) Chemotherapy of Malignant Melanoma. Cancer. 30: 1604-1615.
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1975
MELANOTIC TUMOURS OF THE HAND P. B A N Z E T , J. G L I C E N S T E I N and C. D U F O U R M E N T E L , Paris There are two main problems concerning melanotic tumours of the hand. First, the diagnosis, which is often fairly difficult to make, particularly for malignant types. The second problem is their treatment, completely different for benign and malignant tumours. PROBLEMS OF DIAGNOSIS Melanotic tumours of the hand are lesions of widely varying significance. Some naevi appear safe, and definitely benign. Small pigmented turnouts often arise on the hand or the digits as they do in every other skin area. The dorsum of the hand is also a well known site for blue naevi. Although its dark colour m a y frighten, such a lesion will very rarely become malignant. It should be regarded normally as benign. Giant hairy and pigmented naevi may also involve the hand. They often also cover a large part of the forearm. Of course, m a n y years later a malignant melanoma could occur. But in fact, their surgical removal is often requested for aesthetic reasons earlier. T h e extensive verrucous naevus can sometimes lead to a squamous cell carcinoma. This would be a reason to propose prophylactic surgery, but, here also, the aesthetic problem is often sufficient reason for the patient to request excision of his lesion at an early date. There is a very high risk of subsequent malignancy, in some naevi which are at first benign. These are s u b u n g u a l n a e v i . They appear as a pigmented band, lying on the nail bed, involving its whole length, the matrix, and even the nail wall and fold. Discovering such a lesion early is very important, as, m a n y pathologists believe that it will eventually become malignant melanoma. Of course, one can mistake m a n y other lesions for malignancy, such as subungual benign papilloma, subungual foreign bodies, subungual glomus tumours, or even the c o m m o n subungual haematoma. But, if there is any doubt about the nature of a subungual pigmented naevus, one-block excision biopsy of the whole lesion is mandatory, followed by careful histopathology. The development of frank malignancy in these lesions is often a long delayed process; one could believe that it is a type of superficial spreading m e l a n o m a with secondary development of a nodular tumour. If so, the earlier the surgery, the safer it should be. Malignant m e l a n o m a can present in various ways on the hand It m a y look like typical skin m e l a n o m a in one of the various types, wellknown and described by Clark (1969) as superl~cial spreading or nodular melanoma. It can also be amelanotic. It can also develop in Hutchinson's Freckle; this is not as c o m m o n on the hand, but all these should be detected early and rather easily. F a r more difficult is the problem of the melanotic whitlow and the nail is the commonest site for m e l a n o m a on the hand. At first, it is very hard to detect the malignancy; discovering a little inflammatory halo around the nail base could raise suspicion but the only certain sign is an involvement of the nail; it is then already pretty late in the development of the lesion. Diagnosis is easier when the naevocarcinoma appears not only on the nail bed but also .around the nail base, or on the side of the nail, or the finger tip. The Hand--Vol. 7
No. 2
1975
183
Melanotic Tumors of The HandnP. Banzet, J. Glicemstein and C. Dufourmental
Even so, such a lesion is too often neglected. Often, an injury is related. In other cases, it looks like a chronic infection with a granuloma persisting for months and months. According to our records in Saint Louis Hospital, Paris, we have to treat 7 5 % of our patients after delays varying f r o m a few months to two years, and this seems to prejudice the outcome for our patients greatly. Even under such conditions however, our overall survival rate for melanotic whitlow stands at 35°/° at five years. The h a n d is not the worst site for malignant m e l a n o m a and we think that an early diagnosis should greatly improve the survival rate. We believe that focussing attention on this aspect is the main purpose of writing about melanotic tumours of the hand. TREATMENT
Benign naevi provide a typical field for plastic hand surgery. All surface naevi can be removed, and the wound closed by direct suture, or sometimes covered by secondary healing. The extensive types will require wide excision. Cover will sometimes be possible by rotation flaps, but more often will need skin grafts; full thickness skin on the volar side, split skin on the dorsum. The classical rules about choosing a safe position and good orientation for the scars in order to avoid contraction and preserve function are of course of the greatest importance. F o r Malignant m e l a n o m a we believe that the problem is completely different. Such a lesion can require a multidisciplinary approach where the surgical stage is not the most important. Of course, ablative surgery is still one of the basic steos but chemotherapy and i m m u n o t h e r a p y have also to be harmoniously included. Removing malignant melanoma lying in the skin covering the hand is straightforward, and a wide excision is possible without severe functional defect. But on the digits and for melanotic whitlow the only possibility is to perform an amputation. Even so, according to the anatomical conditions, the excision will not be very wide. As such an amputation on the thumb is necessarily restricted we believe that one is justified in including surgery in a combined treatment, to try to minimise the extent of the resection and thus salvage some important elements of function. Such a conservative attitude does not seem, according to our own statistics, to have any significant effect on the anticipated survival rate and improves greatly the residual hand function of the patient. The wideness of the excision does not appear to be an overwhelming factor influencing prognosis at this site in a combined therapeutic approach. REFERENCES
CLARKE, W. H., FROM, L., BERNARDINO, E. A., and MIHM, M.C. (1969) The Histogenesis and Biologic Behavior of Primary Human Malignant Melanomas of the Skin. Cancer Research, 29: 705-726. DUFOURMENTEL, C., MOULY, R., BANZET, P., PREAUX, J., and GLICENSTEIN, J. (1968) Le Panaris M61anique: M61anome malins sous et p6ri ungu6al. Apropos de 22 cas. Memoires de l'Acad6mie de Chirurgie 94: 309-314. LEPPARD, B., SANDERSON, K. V. and BEHAN, F. (1974) Subungual Malignant Melanoma: Difficulty in Diagnosis. British Medical Journal, 1:310-312. LUCE, J. K., (1972) Chemotherapy of Malignant Melanoma. Cancer. 30: 1604-1615.
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