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Functional surgery for subungual melanoma: when is it indicated?
Apresentação do caso
A 40-year-old male patient complaining of a spot on the right hallux nail for 5 years, with progressive lesion growth. Dermatological examination revealed an extensive, irregular band of melanonychia, ill-defined borders and right hallux nail onychodystrophy. A skin biopsy of the corresponding nail bed was performed, the anatomopathological result was melanoma in situ. We chose to perform conservative surgery for acral melanoma, with millimetrically free margins, confirmed by the pathology in the perioperative period
Nail melanoma comprises about 0.7 to 3.5% of all melanomas, but due to the delay in diagnosis, its prognosis is poor compared to other types. Hutchinson, who was the first to describe subungual melanoma in 1886, has spread the treatment of applied radical surgery since then. In the case of radical amputation of the hallux, it is recommended to preserve, when possible, the head of the metatarsal bone in order to maintain gait physiology. The management of nail melanomas has been questioned and redefined, as conservative surgeries can preserve fingers as much as possible without compromising the safety margin. When considering functional surgery for the treatment of subungual melanoma in situ, histological analysis of all margins of the surgical specimen becomes necessary. In 2002, Clarkson and colleagues excised two melanomas in situ from the same nail, preserving the distal phalanx, followed by flap reconstruction. This type of conservative surgical approach has been increasingly widespread, achieving great functional and esthetic results, without altering the patients' prognosis. Several other authors have also shown good therapeutic results, with no recurrences. Studies demonstrate that no statistical differences were observed in the local recurrence rate of subungual melanomas in situ when undergoing functional surgery compared to amputations.
The conservative excision of nail melanoma in situ offers better aesthetic and functional results, when compared to radical surgery, without affecting the patients' prognosis. With this in mind, we aimed at the case of a patient treated at INCA, who underwent functional surgery for the treatment of acral melanoma, with millimetrically negative margins, preserving functionality prior to returning to daily activities, without oncological impairment. His report is important in the scientific community for the future of surgical treatment for melanoma.
melanoma; Functional surgery; in situ
SARAH HULLIANE FREITAS PINHEIRO DE PAIVA, JADIVAN LEITE DE OLIVEIRA, JULIANA VETORAZO ALVARENGA, ROBERTO ANDRE TORRES VASCONSCELOS, LUIZ FERNANDO NUNES, NELSON JOSE JABOUR FIOD, LALYA CRISTINA SARMENTO DE FREITAS, KAIQUE TORRES FERNANDES, PRISCILA FERREIRA SOTO, RAFAEL LEAL DE MENEZES