Acral lentiginous melanoma (ALM) is an uncommon melanoma type among Caucasions. ALM bears an unfavorable prognosis because of late presentation or common misdiagnosis. Amelanotic variants, albeit rare, may pose an additional clinical challenge and may further delay the diagnosis and treatment. Thus, the threshold for biopsying even marginally suspicious lesions should be low. We present two cases of Caucasian patients with amelanotic subungual ALM, stage 2a and 2c respectively, successfully treated with a functional amputation.
Subungual melanoma (SUM) is a rare subtype in Caucasians. Histologically, most tumors are of the acrolentiginous type (ALM). This is a retrospective analysis of the years 2002–2019 at a certified skin cancer center. We observed 12 SUM patients with a median age of 76 years, seven men and five women (0.6% of all melanomas). The delay of diagnosis reached from 30 years to several months. Hallux and thumb were the most affected localizations. The dominant histologic type was ALM. Clinical symptoms were nail plate destruction (90.9%), bleeding (50.0%), pigmentation of the nail plate (33.3%), and a positive Hutchinson sign (25.0%). All tumors were treated surgically with three‐dimensional margin control. In six patients, amputation was performed. Median relapse‐free survival and overall survival were (56 ± 73.5) months and (112.5 ± 135.1) months, respectively. SUM is rare among Caucasian patients. Nail plate pigmentation and Hutchinson sign were not frequent. Amelanotic ALM with nail plate destruction was the dominant presentation in our series. Dermoscopy is of limited value for amelanotic subungual tumors. Early biopsy of unusual or treatment resistant nail disorders is recommended.
Sir: To evaluate drainage volume, complications, and the diagnostic value of ultrasound-guided (US-guided) thoracentesis in a surgical intensive care unit (SICU), a prospective analysis was performed of all patients who had undergone thoracentesis in the SICU from January 1995 to December 1997. In addition, the impact of patient compliance on the complication rate was observed. Statistical analysis was carried out by the SPSS 8.0 software package using the Spearman rank test.Thoracentesis was performed under 5.0 MHz US scan control with a 2.1-mm needle at the bedside. Chest radiography was performed before and after thoracentesis. A total of 338 thoracenteses were performed in 203 patients (mean age 65.4 years); 59 patients (29 %) were treated because of a gastrointestinal neoplasm, 49 (24 %) were trauma patients, who had a thoracentesis generally after thoracic trauma, 37 patients (18 %) had the procedure after other abdominal surgery, and 20 patients (10 %) had pancreatitis. The remaining 38 patients (19 %) underwent other operative procedures. In 83 cases thoracentesis was carried out in ventilated patients, in 139 cases patients were awake but not compliant, and in 116 cases of thoracentesis patients were alert and cooperative.The average volume of pleural drainage was 616 ml (range 1±4000 ml, SD 454 ml). Altogether, 135 patients (67 %) underwent thoracentesis once, 32 patients (16 %) had a second thoracentesis, 18 patients (9 %) three times and 18 patients (9 %) had more than three. If more than one thoracentesis was necessary, the average period of time between two procedures was 5.2 days (range 1±28 days). In 6 patients (3 %) with neoplasms, pleural infiltration of the neoplasm was verified. In 9 cases (4.4 %), bacteria in the pleural effusions were detected. Complications appeared in 8 procedures (2.4 %): 4 patients (1.2 %) developed a pneumothorax, in one of whom it was drained. Two patients (0.6 %) with initial hemothorax had recurrent hemothoraces and underwent tube drainage, after two thoracenteses (0.6 %) a new hemothorax required thoracotomy.Statistics on the complication rate showed no correlation related to patient compliance (p = 0.38).
BACKGROUND: Cutaneous squamous cell carcinoma (SCC) of the hand is the most common soft-tissue malignancy in this particular region. A literature survey suggested a higher rate of metastases in advanced SCC of the hand compared to head-and-neck cutaneous SCC. CASE REPORT: An 84-year-old man presented with an ulcerated firm tumour on the dorsum of his right hand. A diagnostic biopsy confirmed the diagnosis SCC. Imaging suggested an involvement of the tendons of digits 3 and 4. A diagnostic ultrasound suggested a loco-regional axillary lymph node metastasis. After discussion in the interdisciplinary tumour board, amputation of the affected digits followed by lymph node excision was recommended. CONCLUSIONS: Advanced SCC of the hand requires interdisciplinary management. Amputation is part of the surgical spectrum in advanced cases.
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