Acral Lentiginous Melanoma: Do Surgical Approach and Sentinel Lymph Node Biopsy Matter?

Abstract

Background: Management of acral lentiginous melanoma (ALM) remains controversial. Traditionally, ALM was managed with digit amputation (DA), resulting in significant morbidity, but recent evidence has advocated for digit sparing management. Furthermore, the significance of nodal metastasis for ALM is not well reported. The aims of this study were to determine if surgical approach for primary ALM impacts outcomes and to evaluate the predictive value of nodal status for ALM. Methods: Patients with localized ALM diagnosed from 1982 to 2017 were retrospectively identified. Clinicopathologic characteristics were correlated with surgical approach, nodal metastasis, overall survival, and recurrence-free survival. Results: There were 47 patients with ALM. Median age was 59 years, and median thickness was 3 mm. 51% of patients underwent wide local excision (WLE), 27.9% underwent DA, and 20.9% underwent partial digit amputation (PDA). ALM on the hand versus foot (OR: 12.7, 95%, confidence interval (CI), 2.0–80.1; P = 0.007) and subungual versus nonsubungual location (OR: 28.0, 95% confidence interval, 2.7–295.7; P = 0.006) were significantly associated with surgical approach (DA and PDA versus WLE). There were no significant differences in overall survival or recurrence-free survival between DA, PDA, or WLE cases (P = 0.481 and P = 0.778, respectively). There were no significant differences in overall survival or recurrence-free survival based on nodal status (P = 0.562 and P = 0.136, respectively). Conclusions: No significant differences in overall survival or recurrence-free survival were seen between ALM patients treated with DA, PDA, and WLE. Given these results, PDA or WLE may be options in select patients with digital ALM; however, careful consideration must be taken when deciding on the surgical approach.

Development and validation of two online dynamic nomograms for patients with non‐distant metastatic cutaneous melanoma based on surgical approaches

“…A typical example is ALM: patients with ALM are more likely to undergo amputation because of its prevalence at the extremity (29.70% [amputation group] vs 3.42% [excisional surgery group]) (Table 1). However, the prognosis of ALM after amputation was not significantly different from other pathological subtypes, and therefore ALM could not be a prognostic factor (Table 2), in agreement with the results of previous studies 34–36 …”

“…However, the prognosis of ALM after amputation was not significantly different from other pathological subtypes, and therefore ALM could not be a prognostic factor (Table 2), in agreement with the results of previous studies. [34][35][36] Finally, given that the prognostic factors differed so much between the excisional surgery and amputation groups, we constructed nomograms to predict MSS by combining other meaningful clinical data variables, respectively. They showed good accuracy and utility in the validation of internal data and external data from Affiliated Drum Tower Hospital, Medical School of Nanjing University, with good predictive performance even compared with the AJCC 8th staging system.…”

“…However, the prognosis of ALM after amputation was not significantly different from other pathological subtypes, and therefore ALM could not be a prognostic factor (Table 2 ), in agreement with the results of previous studies. 34 , 35 , 36 …”

Current Controversies in Melanoma Treatment

“…21 For thicker tumors, overall survival is similar between a digit-sparing approach and amputation; a higher risk for local recurrence is seen with more conservative surgery. 22 High patient…”

“…21 For thicker tumors, overall survival is similar between a digit-sparing approach and amputation; a higher risk for local recurrence is seen with more conservative surgery. 22 High patient satisfaction and acceptable aesthetic outcomes have been realized with digit-sparing conservative management. 23 Table 1 offers an algorithm based on tumor thickness, and Figure 2 suggests a plane of resection to remove the nail apparatus and surrounding margin.…”