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Acral lentiginous melanoma mimicking benign disease: The Emory experience,☆☆,,★★

A portion of these data was presented in poster form at the 19th World Congress of Dermatology, Sydney, Australia, June 1997.
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Abstract

Background: Plantar and subungual melanoma exhibits a higher misdiagnosis rate relative to other anatomic sites. Misdiagnosis and delay in diagnosis are statistically associated with poorer patient outcome. Awareness of atypical presentations of acral melanoma may, thus, be important to decrease misdiagnosis rates and improve patient outcome. Methods: We conducted a retrospective case review of plantar or lower-extremity subungual melanoma performed at Winship Cancer Center, a tertiary care, referral center affiliated with Emory University, between 1985 and 2001. Results: A total of 53 cases of plantar or lower-extremity subungual melanoma were identified. Of 53 cases with a final diagnosis of melanoma, 18 were initially misdiagnosed. Misdiagnoses included wart, callous, fungal disorder, foreign body, crusty lesion, sweat gland condition, blister, nonhealing wound, mole, keratoacanthoma, subungual hematoma, onychomycosis, ingrown toenail, and defective/infected toenail. Of the 18 misdiagnosed cases, 9 were clinically amelanotic. Conclusion: Awareness that amelanotic variants of acral melanoma may assume the morphology of benign hyperkeratotic dermatoses may increase the rate of correct diagnosis and improve patient outcome. (J Am Acad Dermatol 2003;48:183-8.)

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Methods

Cases of plantar and lower-extremity subungual melanoma were retrieved from the tumor registry of the Winship Cancer Center for the time period 1985 to 2001, inclusive. The Winship Cancer Center is a tertiary care, referral center affiliated with Emory University School of Medicine. The center subsumes the Emory Melanoma and Pigmented Lesions Center, which provides specialized, multidisciplinary care for patients with melanoma from the standpoints of medical oncology, surgical oncology,

Results

A total of 53 cases of plantar or lower-extremity subungual melanoma were identified during the study period. Of 53 cases with a final diagnosis of melanoma, 18 received a prior clinical diagnosis other than melanoma (Table I).

. Patient and clinical characteristics

Patient No.Age (y)SexRaceTumor siteInitial diagnosisBreslow thickness at diagnosis (mm)Outcome
175FCaucasianLeft soleCallus2.94Alive; NED
279FCaucasianRight soleNonhealing ulcer6.00DOD
363FCaucasianRight soleCrusty lesion1.50Alive; NED
462M

Discussion

Misdiagnosis and delay in diagnosis are relevant topics in the discussion of a cancer that is eminently curable by conservative operation in its early stages, but associated with extremely poor outcome in advanced states. One retrospective study of 83 patients with acral melanoma reported a 36% clinical misdiagnosis rate3 with increased median tumor thickness (5 vs 1.5 mm), more advanced stage at diagnosis (stage IIIb and IV; 30% vs 5.6%), and lower estimated 5-year survival (15.4% vs 68.9%)

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Funding sources: None.

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Conflict of interest: None identified.

Reprint requests: Carl V. Washington, MD, Emory University School of Medicine, Department of Dermatology, 5001 Woodruff Memorial Bldg, Atlanta, GA 30322. E-mail: [email protected].

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0190-9622/2003/$30.00 + 0

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