In-Service Exam
Melanoma - 2002





Hutchinson's freckle is another name for which of the following types of melanoma?

(A) Acral-lentiginous
(B) Lentigo maligna
(C) Mucosal
(D) Nodular
(E) Superficial spreading

The correct response is Option B.

Hutchinson's freckle is a misleading term for lentigo maligna melanoma, a melanoma in situ that is found within the layers of the epidermis only. This lesion typically occurs in fair-skinned, elderly persons and manifests as a macule or patch of darkened skin on the face or other sun-exposed areas. Although 5% to 10% of all melanomas can be classified as lentigo maligna, the risk for development of invasive melanoma in affected patients has been shown to range from 5% to 30% in various studies. Slow growth, often for a period of 10 to 20 years, is common initially and is then followed by an aggressive, invasive phase.

References
1. Harris AO, Levy ML, Goldberg LH, et al. Nonepidermal and appendageal skin tumors. Clin Plast Surg. 1993;20:115-130.
2. Schaffer JV, Bolognia JL. The clinical spectrum of pigmented lesions. Clin Plast Surg. 2000;27:391-408.
3. Titus-Ernstoff L. An overview of the epidemiology of cutaneous melanoma. Clin Plast Surg. 2000;27:305-316.

A 42-year-old woman has a pigmented matrix lesion on the index finger. Biopsy of the lesion shows a subungual melanoma. Which of the following is the most appropriate management?

(A) Ablation of the nailbed and matrix resurfacing with skin grafting
(B) Amputation at the distal interphalangeal joint
(C) Amputation at the proximal interphalangeal joint
(D) Ray amputation

The correct response is Option B.

This patient who has a subungual melanoma of the index finger should undergo amputation at the level of the distal interphalangeal joint. In patients with histologically confirmed subungual melanoma, the recommended level of amputation is somewhat controversial; however, conservative management (ie, amputation at the level of the joint located just proximal to the lesion) is recommended to preserve function. Ray amputation, a more aggressive alternative, is still advocated by some surgeons. Studies have reported a five-year survival rate of 66% in patients diagnosed with subungual melanoma.

This patient should undergo a complete physical examination, radiographs of the hand, and CT scans of the chest, head, abdomen, and pelvis. Although the role of elective lymph node dissection in the management of subungual melanoma is controversial, sentinel lymph node dissection may be helpful in patients who have tumors of intermediate thickness (1.0 to 4.0 mm).

Ablation of the nailbed and matrix resurfacing with skin grafting is appropriate management of melanoma in situ of the matrix, also known as melanocytic dysplasia.

References
1. Finley RK III, Driscoll DL, Blumenson LE, et al. Subungual melanoma: an eighteen-year review. Surgery. 1994;116:96-100.
2. Glat PM, Shapiro RL, Roses DF, et al. Management considerations for melanonychia striata and melanoma of the hand. Hand Clin. 1995;11:183-189.
3. Heaton KM, el-Naggar A, Ensign LG, et al. Surgical management and prognostic factors in patients with subungual melanoma. Ann Surg. 1994;219:197-204.