A rare presentation of a subungual melanoma with distant metastasis

Anurag Bhattacharjee; Bhavaniprasad Kalagani; Ravi Ponnugoti; Harshal Ramteke; Samarth Shukla; Niveditha Suresh

doi:10.4103/jdmimsu.jdmimsu_360_20

CASE REPORT

Year : 2020 | Volume : 15 | Issue : 3 | Page : 506-509

A rare presentation of a subungual melanoma with distant metastasis

Anurag Bhattacharjee¹, Bhavaniprasad Kalagani¹, Ravi Ponnugoti¹, Harshal Ramteke¹, Samarth Shukla², Niveditha Suresh¹
¹ Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
² Department of Pathology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission	11-Sep-2020
Date of Decision	25-Sep-2020
Date of Acceptance	30-Sep-2020
Date of Web Publication	1-Feb-2021

Correspondence Address:
Dr. Anurag Bhattacharjee
T7, Raghobaji Hostel, Sawangi, Meghe, Wardha - 442 001, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_360_20

Abstract

Subungual melanoma is a rare melanoma globally and melanoma by itself is reported rarely from the Indian population. This case is being reported for the rare occurrence of subungual melanoma in the Indian population and also for presentation with a long history of the lesion with no evidence of metastasis. Hereby presenting a rare case of a 40-year-old male who presented with blackish discoloration and ulcer of the left index fingernail of 5 months' duration post history of trauma to the index finger. Examination revealed black dystrophic left index fingernail. A detailed examination showed a mass under the dystrophic nail. Histopathology revealed characteristic features of melanoma. A detailed evaluation revealed features of regional metastasis. The entire finger was then amputated surgically by disarticulation at the metacarpophalangeal joint and regional nodes removed by ipsilateral axillary dissection.

Keywords: Hutchinson's, melanoma, metastasis, subungual

How to cite this article:
Bhattacharjee A, Kalagani B, Ponnugoti R, Ramteke H, Shukla S, Suresh N. A rare presentation of a subungual melanoma with distant metastasis. J Datta Meghe Inst Med Sci Univ 2020;15:506-9

How to cite this URL:
Bhattacharjee A, Kalagani B, Ponnugoti R, Ramteke H, Shukla S, Suresh N. A rare presentation of a subungual melanoma with distant metastasis. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 7];15:506-9. Available from: http://www.journaldmims.com/text.asp?2020/15/3/506/308567

Introduction

Subungual melanoma or melanotic whitlow is a relatively rare disease with a reported incidence between 0.7% and 3.5% of all melanoma cases in the general population.^[1] Despite the significant improvement in the diagnosis of cutaneous melanomas, the diagnosis of subungual melanoma remains difficult.^[2] Despite its visibility and easy accessibility, it is often misdiagnosed, and thus there is a delay in treatment. This delay in recognition often results in poor prognosis.^[3] All persistent nail lesions, which do not respond to conservative treatment, whether pigmented or not, should undergo excisional biopsy and pathologic examination. A case of subungual melanoma is presented to highlight the typical presentation and clinical characteristics, which help in its early diagnosis and subsequent management.^[4] Early detection and awareness is the key to successful treatment outcome and prognosis of the patients.

Case Report

This 40-year-old male patient presented with a 5 months' history of gradually progressive blackish discoloration and ulcer of his left index fingernail. There was associated history of insidious onset gradually progressive swelling of the distal aspect of the left index finger. Mild pain was present. There was a history of trauma before the onset of complaints. There was a history of discharge and itching occasionally. He had taken multiple oral and topical medicines including several courses of oral antifungals with no relief. He is a known diabetic.

Examination revealed diffuse mildly tender swelling involving the distal part of the left index finger, distal to the interphalangeal joint [Figure 1]. The overlying nail plate was hyperpigmented and dystrophic. Hyperpigmentation was also present on the proximal nail fold, hyponychium, and periungual areas. The entire distal part of the finger has black necrotic granulation tissue with scant purulent nonfoul smelling discharge in between the layers of the dystrophic nail plate. There was a palpable single, mobile lymph node of size 2 cm × 2 cm in the ipsilateral axilla (regional lymphadenopathy). The systemic examination was normal.

Figure 1: Clinical photo of subungual melanoma

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A wedge biopsy from the left index fingernail bed was sent for histopathological examination, which revealed features of malignant melanoma. Investigations such as hemogram, urinalysis, liver and renal functions, and ultrasound abdomen were within normal limits. Ultrasound axilla revealed ipsilateral multiple lymph nodes.

The patient underwent amputation of the entire finger along with axillary lymph node dissection [Figure 2] and [Figure 3].

Figure 2: Intraoperative image (Amputation of left index finger)

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Figure 3: Axillary dissection of metastatic lymph node

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Resected margins were found to be free of tumor tissue [Figure 4]. Histopathology revealed sheets of cells varying in shape from polygonal to spindle. The spindle cells had scanty cytoplasm, pleomorphic oval to spindle hyperchromatic nuclei. Some of these nuclei were angulated. Some cells were polygonal with large coarse nuclei and prominent macronuclei. Many of the cells contained intracytoplasmic golden brown pigment. Areas of necrosis and mitotic figures were seen. A final diagnosis of malignant melanoma with metastasis was given based on the histopathological features.

Figure 4: Intraoperative image of amputated left index finger and axillary lymph node

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The postoperative period was uneventful. On follow-up suture sites healed well [Figure 5] and [Figure 6].

Figure 5: Clinical image of postoperative healthy suture line

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Figure 6: Histopathological report

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Discussion

Pigmented lesions of the nail unit may be due to a wide variety of benign and malignant causes. Melanoma is the most common malignant lesion seen in the nail unit. Subungal melanoma is a rare form of melanoma. Overall, 62% of subungual melanomas present under the fingernails with 38% presenting under toenails.^[3] Subungual hematoma, pyogenic granuloma, or onychomycosis may have a similar clinical presentation.^[5] Literature has documented that direct trauma is related to the onset of subungual melanoma. This might be explained by coincidence, increased attention to a dark area under the nail, traumatic bleeding of a subclinical subungual melanoma, or mutation of melanocytes during trauma-induced proliferation. Squamous cell carcinoma is known to occur in sites of chronic trauma.^[6] Trauma could be an etiologic factor in subungual melanoma as well. Histological diagnosis is the most definitive way of identifying such a lesion and can prevent significant morbidity and mortality. Suspicious signs to be aware of are nail fold pigmentation, lifting off of the nail from the nail bed, and ulcerating lesions that do not heal.^[7] A very useful approach is the “ABCDEF” rule,^[2] for the clinical detection of subungual melanoma as shown in [Table 1]. These can be applied similarly to the “ABC” approach to detecting cutaneous melanoma, which has led to early identification. The estimated 5-year survival is between 16% and 87%.^[8] Prognosis depends heavily on the thickness of the tumor, termed the Breslow thickness, the stage of the tumor, and the degree of tumor invasion. Breslow thickness is known to be a good prognostic indicator for subungual melanoma, even though it is less accurate than that for cutaneous melanoma.^[9] Up to 25% of patients can present with lymph node or distant metastases. Subungual melanoma presents in a more disguised manner than cutaneous lesions and therefore, requires increased vigilance and awareness.^[1] That is why any unresolved subungual lesion of any kind should raise suspicion until proven otherwise, and early biopsy of the lesion is warranted as soon as possible along with a thorough clinical examination of regional and distant lymph nodes.^[10] Early detection in malignant melanoma is vital for improved treatment outcomes and prognosis.^[11] Due to extreme rarity in the Indian population, subungual melanoma is rarely reported in the literature from this country, and cases are missed in their earlier stages.^[1] Another interesting fact is the absence of local or distant metastasis despite the long history however the presence of distant metastasis is also a rare phenomenon. It is also believed that traumatic injury may be the initial cause for developing subungual melanoma. In our case, we are unsure of whether trauma is the cause of the subungual melanoma, or whether the injury brought a preexisting lesion to light.^[9] Nevertheless, our take-home message is that an unresolved subungual lesion of any kind should raise suspicion until proven otherwise and warrant early referral to a skin cancer specialist unit. A biopsy of the lesion is warranted as soon as possible along with a thorough clinical examination of regional and distant lymph nodes.^{[12],[13],[14],[15],[16]}

Table 1: Features of subungual melanoma

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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