Mohs micrographic surgery for nail unit tumours: an update and a critical review of the literature.

Mohs micrographic surgery (MMS) is a good treatment option for epithelial neoplasms, especially when localized in areas where tissue conservation is crucial, such as the nail unit (NU). MMS is a method of radical excision offering high cure rates due to the margin control and functional preservation. Our aim is to provide a review on the use of MMS for the treatment of the most common nail tumours. We revised the current literature on the use of MMS to treat malignant neoplasms (Bowen's disease, squamous cell carcinoma, melanoma, basal cell carcinoma, keratoacanthoma, carcinoma cuniculatum) and benign neoplasms (onychomatricoma and glomus tumour). MMS represents a successful surgical option for nail tumours, firstly in terms of tissue conservation: the NU anatomy is complex and the preservation of the component structures is imperative for its functionality. Secondly, due to the surgical radicality, which is essential not only for the clearing of malignant tumours, but also for benign cases, in order to reduce recurrences. Although a conservative treatment of NU melanoma with MMS has been proposed, in our experience, the conservative approach with functional surgery is a good option for the treatment of non-invasive melanoma (in situ and Ia).

Nail apparatus melanoma: dermoscopic and histopathologic correlations on a series of 23 patients from a single centre.

BACKGROUND: Nail apparatus melanoma (NAM) is an uncommon tumour, and there are few studies focused on its dermoscopic features. OBJECTIVE: The aims of our study were to evaluate the diagnostic accuracy of dermoscopy in NAM. A diagnostic algorithm for adult patients with suspected NAM is proposed. METHODS: We collected NAM dermoscopic images of patients with a proven histopathology from 2008 until 2015. Clinical and dermoscopic images were blindly examined by two dermatologists, and correlations between histopathological aspects and dermoscopic features were investigated. RESULTS: We retrospectively collected NAM dermoscopic images associated with a proven histopathology of 23 Caucasian patients. Only cases with available both preoperative dermoscopic images and bioptic specimens were included. Seventeen women and six men were included. The mean age at diagnosis was 63 years (range 18-92). CONCLUSION: We created an algorithm to indicate the correct way to follow an adult patient with suspected NAM. This algorithm may ameliorate management in case of suspected NAM and possibly facilitate an early diagnosis.

Oral melanoma and other pigmentations: when to biopsy?

Oral pigmentations (OPs) are often neglected, although a meticulous examination of the oral cavity is important not only in the diagnosis of oral melanoma, but also for the detection of important clinical findings that may indicate the presence of a systemic disease. OPs may be classified into two major groups on the basis of their clinical appearance: focal and diffuse pigmentations, even though this distinction may not appear so limpid in some cases. The former include amalgam tattoo, melanocytic nevi, melanoacanthoma and melanosis, while the latter include physiological/racial pigmentations, smoker's melanosis, drug-induced hyperpigmentations, postinflammatory hyperpigmentations and OPs associated with systemic diseases. We will discuss the most frequent OPs and the differential diagnosis with oral mucosal melanoma (OMM), underlining the most frequent lesions that need to undergo a bioptic examination and lesions that could be proposed for a sequential follow-up.

Genital melanocytic naevus on lichen sclerosus: an uncommon occurrence and a management proposal.

BACKGROUND: Melanocytic naevi located in special sites, such as the vulvar mucosa might present peculiar clinical and dermatoscopic features. OBJECTIVES: We describe a management proposal of a genital naevus associated with inflammatory disorders that aims to facilitate the clinical and pathologic diagnosis. METHODS: Videodermoscopy of a genital naevus associated with lichen sclerosus of an 8-year-old girl, was carried out before and 2 months after treatment with topical steroids. An excisional biopsy and immunohistochemical studies with HMB-45, MART -1 and molecular studies with p 16 staining were performed. RESULTS: The features of the melanocytic lesion associated with lichen sclerosus were troublesome on the basis of clinical and videodermoscopic evaluation. Histopathologic and immunohistochemical examination performed after topical treatment, showed a compound melanocytic naevus with an underlying inflammation consistent with lichen sclerosus. CONCLUSIONS: The evaluation of genital naevi should take into account the presence of inflammatory disorders, not uncommon in such location. Treatment of the latter and short follow-up of the patients, can avoid over-diagnosis of malignancies and extensive surgical procedures.

Nail apparatus melanoma: is trauma a coincidence? Is this peculiar tumor a real acral melanoma?

Nail Apparatus Melanoma (NAM) is rare, particularly in Caucasians. Understanding its pathogenesis and collecting epidemiologic data may be difficult due to its location and the exiguity of the case series of this cancer. Cutaneous melanoma has been thought related to UV radiation, and NAM is considered an acral variant of melanoma, even if the nail presents a specific anatomy. Little is reported about pathogenesis, except reports suggesting traumatic injuries as a causal factor. UV exposure is debated in nail melanoma because of its structure. The nail is, in fact, a unique structure with sun-exposed and non exposed melanocytes. NAM arises from the nail melanocytes, located in the nail matrix, which is the germinative part of the nail and composed of a proximal and distal portion. The proximal nail matrix lays under the proximal nail fold that covers it and is non-sun exposed, while the distant nail matrix, clinically visible as the lunula, is sun-exposed, though lying underneath the nail plate. According to these anatomical data, NAM is a distinct melanoma type, and studies need to classify it as acral melanoma or as a particular type of melanoma with its own pathogenesis and prognostic criteria. This study investigates potential risk factors of NAM, emphasizing (i) trauma and (ii) UV exposure among our NAM patients.

Mohs surgery for squamous cell carcinoma of the nail: report of 15 cases. Our experience and a long-term follow-up.

BACKGROUND: Subungual squamous cell carcinoma (SSCC) is the most common malignancy of the nail unit. Mohs micrographic surgery (MMS) is a microscopically controlled surgical technique that has a high cure rate for skin cancers despite allowing narrow surgical margins. OBJECTIVE: To evaluate the long-term effectiveness of MMS in the treatment of SSCC, and in particular its ability to reduce the number of digital amputations. METHODS: Fifteen patients diagnosed with SSCC were treated with MMS as the first-line surgical approach, and were followed up for between 2 and 5 years. RESULTS: SSCC was completely excised in 13 patients, while two patients required amputation of the distal phalanx. For tumours with predominantly exophytic growth, clinical and radiological findings were found not to be reliable indicators of bone invasion. No recurrences were detected on follow-up. CONCLUSION: Our results show that MMS provides a high cure rate for SSCC and reduces the number of amputations needed. MMS should become the first-line surgical approach for SSCC.

Evaluation of incidental thyroid nodules in patients with primary melanoma.

AIM: Literature data have suggested an increase of incidental thyroid nodules in patients with malignancies, including melanoma. METHODS: The ultrasound findings of 168 consecutive melanoma patients were revisited in order to evaluate the presence of incidental thyroid nodules and the results were compared with clinical features, Breslow thickness and the rate of malignancy of incidental thyroid nodules. RESULTS: We observed that: 1) incidental thyroid nodules are more frequent in patients affected by melanoma (60.6%) than in the healthy population; 2) no statistically significant difference were found in thyroid involvement on the basis of gender and age; 3) incidental thyroid nodules frequency is increased in patients with thinner melanoma and this increase is more evident if we consider melanoma in situ and female patients; 4) it was not detected malignant incidental thyroid nodules. CONCLUSION: The data revealed a high frequency of incidental thyroid nodules in patients with melanoma, suggesting that it is necessary to study this association in a larger group of patients, also including age/gender matched controls.

Superficial acral fibromyxoma: a clinicopathological and immunohistochemical analysis of 12 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes.

AIM: Superficial acral fibromyxoma (SAFM) is a rare soft tissue tumor, recently delineated and documentated as a separate entity. We report 12 cases of SAFM observed in our department from June 2004 to June 2010 and highlight pathological features and differential diagnosis. METHODS: Radiographic examination of the affected digit was performed in all patients. All the tumors were surgically excised under local anesthesia. Follow-up was made every 6-8 months for a maximum period of five years. RESULTS: The patients consisted of 8 men and 4 women, age range 28-76 years (mean 51), presenting with a solitary mass or nodule located in the toes and fingers. Histologically the lesions were well circumscribed dermal nodules composed of stellate and spindle cells, arranged in a myxoid matrix. Very low grade atypia and a few mitotic figures were found in only one case. Neoplastic cells showed immunoreactivity for CD34 (12 patients). In contrast focally positive or negative staining was shown for the epithelial membrane antigen (EMA) and CD 99. Actin, S100 protein, HMB45 and cytokeratin were negative. In three cases marked hyperkeratosis and acanthosis of the epidermis was present. Pathological analysis confirmed the diagnosis of superficial acral fibromyxoma. No recurrences were observed even in a long term, 2-5 year follow-up. CONCLUSION: Complete surgical excision of the tumors and a careful follow-up is suggested, despite the benign course previously reported.