Surgical Management Of Alm On The Volar Skin
In general, ALMs start as in situ lesions, with brown macules that enlarge slowly and form irregularly pigmented, asymmetric macular lesions over the years, corresponding to the radial growth phase. Thereafter, indurated nodules appear within the macular lesions and sometimes the nodules ulcerate in the so-called vertical growth phase.
Prevention And Early Detection
As researchers do not yet know what causes ALM, they also do not know how to prevent it. The best opportunity for a favorable outcome is an early diagnosis. ALM is rare, but it can be deadly. Monitoring the skin for changes can be life-saving.
It is important to schedule annual skin examinations with your dermatologist and to make sure your doctor checks the palms of your hands, the soles of your feet, and your nail beds. If an unexplained lesion appears on your hand, foot, or nail, you should see your dermatologist as soon as possible so that s/he can take a biopsy of the area and decide whether the spot is cancerous. As with any form of melanoma, diagnosing it early is key.
What Happens At Follow
The primary purpose of follow-up is to detect recurrences early.
The Australian and New Zealand Guidelines for the Management of Melanoma make the following recommendations for follow-up for patients with invasive melanoma.
- Self-skin examination
- Routine skin checks by a patient’s preferred health professional
- Follow-up intervals are preferably six-monthly for five years for patients with stage 1 disease, three-monthly or four-monthly for patients with stage 2 or 3 disease, and yearly after that for all patients.
- Individual patients needs should be considered before an appropriate follow-up is offered
- Provide education and support to help the patient adjust to their illness
The follow-up appointments may be undertaken by the patient’s general practitioner or specialist, or they may be shared.
Follow-up appointments may include:
- A check of the scar where the primary melanoma was removed
- A feel for the regional lymph nodes
In those with more advanced primary disease, follow-up may include:
- Blood tests, including LDH
- Imaging: ultrasound, X-ray, CT, MRI and PET scan.
Tests are not typically worthwhile for stage 1/2 melanoma patients unless there are signs or symptoms of disease recurrence or metastasis. And no tests are thought necessary for healthy patients who have remained well for five years or longer after removal of their melanoma, whatever stage.
Sentinel Lymph Node Biopsy On Lower Extremities
In almost all cases, tumours on lower extremities drain to the inguinal region. Figure 6 demonstrates lymphatic drainage for 23 cases with tumours on lower extremities in our institute. Of all 23 cases, the lymph node identification rate was 23 cases for the inguinal region, five cases for the popliteal region and 10 cases for the pelvic region . Three of the 23 cases with SLN on the inguinal region had positive nodes and there were no positive nodes on the popliteal and pelvic region.
The sites of SLNs in primary melanomas on lower extremities.
One of the problems with SLNB of lower extremities is the presence of pelvic SLNs. Kaoutzanis et al. showed 11 of 82 cases with tumour on lower extremities had SLNs on the pelvic region and underwent SLNB . They also showed that 19 of 82 cases had positive SLNs and all the positive SLNs were located in the inguinal region. No positive SLNs were present in the pelvic region as our cases.
Even in SLNB, removing the lymph nodes in the external iliac and obturator region is a relatively invasive technique. It is still controversial whether or not SLNs in the pelvic region should be harvested because SLNs in the pelvic region may be considered as secondary or third lymphatic basin, even when radioisotope is accumulated in pelvic lymph nodes.
Causes Of Acral Lentiginous Melanoma
Unfortunately, there arent any known or proven causes for Acral lentiginous melanoma. Researchers have found that unlike most melanoma or skin cancerous diseases, Acral lentiginous melanoma is not caused or related to sun exposure.
In some people, it has been discovered to have a genetic factor. Those who have relatives with Acral lentiginous melanoma have higher risk of being disease-ridden.
Some scientists believe that an injury to the hand or foot may cause an Acral lentiginous melanoma lesion.
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What Are The Treatment Methods
Treatment for acral melanoma usually consists of removing the cancerous tissue by cutting it out. Treatment depends on many factors, including:1
- Size of the affected area
- Location on the body
- Stage of the disease
- Thickness of the acral melanoma
In some cases where the acral melanoma is larger, a biopsy is taken to confirm the diagnosis. Surgery is then performed to remove the cancerous tissue. A skin graft, which replaces damaged tissue with healthy tissue, may be needed to close the wound.1,3
In extreme cases, doctors will consider partial removal of a finger or toe. Since amputation can greatly affect a persons quality of life, a large clinical trial is currently underway to explore other, less invasive options using newer surgical techniques and skin grafts.1
Acral melanoma does not respond as well to radiation as other melanomas. However, there are some chemotherapy options for those with advanced stages of the disease. If acral melanoma is widespread, immunotherapy is an option, with several drugs showing promise.1,2
What Is The Clark Level Of Invasion
The Clark level indicates the anatomic plane of invasion.
Level 1 In situ melanoma Level 2 Melanoma has invaded the papillary dermisLevel 3 Melanoma has filled the papillary dermis Level 4 Melanoma has invaded the reticular dermisLevel 5 Melanoma has invaded subcutaneous tissue
The deeper the Clark level, the higher the risk of metastasis . It is useful in predicting outcome in thin tumours and less useful for thicker ones in comparison to the value of the Breslow thickness.
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Enhancing Healthcare Team Outcomes
An interprofessional approach is paramount in providing care for patients with ALM. Primary care providers play an important role in patient education and the detection of early changing skin lesions. Once detected, dermatologists are often consulted to confirm the suspicious nature of the lesion and perform the initial biopsies. Evaluation of the lesional biopsy by a trained dermatopathologist is also necessary as the diagnosis is difficult and requires significant clinicopathologic correlation. Treatment may involve multiple specialties include Mohs surgeons, general surgeons, or orthopedic surgeons for definitive excision of the lesion. If metastases are expected, surgical oncology and hematology/oncology should be consulted to facilitate sentinel lymph node biopsy and consider systemic therapies as warranted.
What Are The Clinical Features Of Acral Lentiginous Melanoma
Acral lentiginous melanoma starts as a slowly enlarging flat patch of discoloured skin.
The characteristics of acral lentiginous melanoma include:
- Large size: > 6 mm and often several centimetres or more in diameter at diagnosis
- Variable pigmentation: most often a mixture of brown, and blue-grey, black and red colours
- A smooth surface at first, later becoming thicker with an irregular surface that may be dry or wart-like
- Ulceration or bleeding.
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Acral Lentiginous Melanoma Complications
Large excisions of acral lentiginous melanoma, particularly on the hands, can lead to contractures and painful scarring, which can lead to significant morbidity 46). If digit or limb amputation is required for treatment, patients can experience significant interference with activities of daily living, loss of function of the affected limb, phantom pain, and poor cosmetic outcomes 47).
What Is The Cause Of Acral Lentiginous Melanoma
Acral lentiginous melanoma is due to the development of malignant pigment cells along the basal layer of the epidermis. These cells may arise from an existing melanocytic naevus or more often from previously normal-appearing skin. What triggers the melanocytes to become malignant is unknown, but it involves geneticmutations.
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Types Of Acral Lentiginous Melanoma
The two primary characteristics of ALM are:
- Location: “Acral” means “extremity” in Greek, which describes the location where this skin cancer appears . There’s a subtype of this melanoma that is found in the nail beds, called subungual melanoma.
- Lesion coloration: “Lentiginous” refers to the freckled pigmented appearance of the spots or lesions. They can be a different, darker shade than a person’s skin. However, there are also nonpigmented or amelanotic lesions, which may appear as a red or orange color.
Other Things To Know About Acral Lentiginous Melanoma
As an ALM tumor increases in size, it usually becomes more irregular in shape and color .
The surface of the ALM lesion may remain flat, even as the tumor invades deeply into the skin.
Thickening ALM on the sole of the foot can make walking painful and be mistaken for a plantar wart.
The surface of a spot of ALM may also start out smooth and become bumpier or rougher as it evolves. If a tumor begins to grow from the cancerous skin cells, the skin will become more bulbous, discolored, and rough to the touch.
Less advanced cancers and thinner tumors have better survival rates. Raised tumors tend to be more aggressive.
Men are more likely than women to have thick, large tumors at diagnosis.
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Problems Of Excision Margins In Alm
The World Health Organization Melanoma Program undertook a randomized trial and compared lateral margins of 1 and 3 cm for 612 melanoma patients with thicknesses of < 2 mm . Disease-free and overall survival rates did not differ between the two groups. Two subsequent trials in Europe compared the results of treating melanomas with lateral margins of 2 or 5 cm. The Scandinavian Melanoma Group Study and French Cooperative Group Trial compared lateral margins of 2 cm with 5 cm for patients with 0.82.0 mm-thick and < 2.1 mm-thick melanomas, respectively . Neither study showed any evidence that lateral margins of 5 cm reduced the local recurrence rate or improved survival rates. The Intergroup Melanoma Surgical Trial also reported the results of a randomized prospective trial that compared lateral margins of 2 cm with 4 cm for 740 melanoma patients with thicknesses of 1.014.0 mm . This trial also demonstrated that the local recurrence and survival rates were similar for the two groups. This evidence suggests that lateral margins of at least 2 cm are suitable for patients with melanoma with thicknesses of > 2 mm.
Sentinel Lymph Node Biopsy
Sentinel lymph node biopsy has become the standard procedure used to determine whether a tumour has metastasized to lymph nodes and more accurate staging of the melanoma. It is a less invasive technique than lymph node dissection allowing patients with node negative melanoma to avoid unnecessary lymph node dissection. In the case of SLN positive melanoma, additional surgery of lymph node dissection is necessary.
The false-negative rate in SLN mapping for melanoma has been reported to be very low with a rate of 0 to 2 % . The multicenter selective lymphadenectomy trial-1 demonstrated immediate lymph node dissection following microscopic positive node at SLNB could bring about better prognosis than the lymph node dissection after clinical nodal observation .
For more correct mapping of SLNs, a combination of blue dye and radioisotope 99mTc labelled phytate is generally used. SLNs are identified by the presence of blue stained lymph vessels and lymph nodes, and the radioactivity measured by gamma probe. Furthermore, distinction between SLNs and secondary non-SLNs is achieved by using pre-operative dynamic cutaneous lymphoscintigraphy .
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Alm And People With Dark Skin
ALM is a rare form of skin cancer, comprising 2%3% of all melanoma cases. However, it is the most common type of malignant melanoma in people who traditionally have dark skin, particularly Black Americans, and people of Asian, and Middle Eastern origin.
While sun exposure and other lifestyle factors, such as smoking, have not been linked to ALM, researchers have identified some other factors that may increase your risk of ALM. These include:
- Prior traumatic injury to the hand or foot
- Exposure to certain agricultural chemicals
- Systemic inflammation
However, there is not enough evidence to make a causal link between ALM and any of the aforementioned factors.
Home Remedies And Lifestyle
There are no home remedies or lifestyle factors approved to treat ALM.
However, it is important to note that some lifestyle factors, including avoiding or quitting smoking, maintaining a healthy, nutrient-rich diet, reducing your stress levels, and finding an exercise program that works for you may help you feel better and improve your outcomes as you navigate your cancer treatment and recovery.
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How Is Acral Melanoma Unique
Acral melanoma occurs on the hands and feet the palms, soles, fingers, toes, and underneath the nails. It is not caused by ultraviolet rays, as is often the case with other types of melanoma like cutaneous melanoma.1,2
Acral melanoma starts out looking like a patch of discolored skin. If left untreated, the cancerous cells can spread to a larger area of the skin and to deeper layers of the skin tissue. This can happen over the span of several months and years.3
It is not entirely clear what causes acral melanoma. There is some evidence that stress and trauma to the affected area could increase a persons risk. There may also be a genetic link. More research is needed to understand the true cause.1
Acral Lentiginous Melanoma Differential Diagnosis
The differential diagnoses for a patient presenting with a subungual lesion are broad. Lesions can be divided into melanocytic and non-melanocytic. They can also be categorized as neoplastic, traumatic, infective, systemic and drug-induced.
Acral lentiginous melanoma differential diagnoses could include:
- Melanocytic lesions
Longitudinal melanonychia is a specific appearance of a linear, pigmented band on the nail plate. This appearance in itself is non-specific and can result from the same variety of diagnoses listed above for any subungual pigmentation. Early subungual melanoma often presents as longitudinal melanonychia.
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Acral Lentiginous Melanoma: The Overlooked Cancer
The most common skin cancer among people of color is also one of the least researched. That is changing, finally.
When Suzanne Carothers left North Carolina for graduate school in New York City nearly 50 years ago, she carried with her a weighty book and three pieces of advice.
The book was the Physicians Desk Reference. The pieces of advice: Always do your own research, ask questions, and be an advocate for your health.
Her mother, a Black registered nurse, had often seen Black patients receive inadequate medical care at the hospital where she worked in Charlotte. She wanted her daughter to be informed and prepared.
Carothers heeded her mothers advice. She saw a few moles on her body when she was in her 60s and began seeing a dermatologist. Then, at an annual screening last year, her dermatologist checked the soles of her feet and noticed a dark spot near her heel. It was acral lentiginous melanoma, a rare subtype of melanoma that appears on the palms, on soles of the feet, or under fingernails or toenails.
Carothers, now 71 and also a breast cancer survivor, was lucky: Her dermatologist had caught it early. After having surgeries to excise the cancerous cells and additional skin around the margins, shes in remission. But the majority of ALM patients tend to present later, when the cancer is more difficult to treat. And Carothers now wonders why no one had ever checked for this before.
Causes And Risk Factors
Anyone can develop ALM. Unlike most other forms of melanoma, ALM does not appear to be related to sun exposure. In some people, it may be due to a genetic risk factor.
Death rates from ALM are higher than those of other forms of melanoma. This may be because ALM can go unnoticed longer, allowing it to spread and become more aggressive before treatment begins. Early diagnosis and prompt treatment have a major impact on whether a person will survive. Its important to note that a large number of people who have ALM are initially misdiagnosed with something else.
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Problems Of Excision Margins
Because of this very slow clinical course, ALMs on the volar skin often contain in situ lesions at the periphery . Based on the recommended lateral margins described above, the dermatological surgeons are often confused regarding the decision for lateral margins. It is still unclear whether lateral margins of 0.51 cm from the peripheral border of the lesion should be suitable as the peripheral lesion is considered an in situ lesion, or lateral margins of 2 cm from the periphery of the lesion should be selected as the entire tumor itself is regarded as an invasive lesion.
Acral Lentiginous Melanoma Risks
Because acral lentiginous melanoma isnât a result of increased sun exposure, genetics may be a contributing factor to its development. If you know of a family member who was diagnosed with acral lentiginous melanoma, you may be at a greater risk for the condition as well.â
Acral lentiginous melanoma death rates are higher than with other types of melanoma because it often goes unnoticed for so long. This is why it is important to talk to your doctor any time you notice changes in your skin that arenât temporary.â
Itâs also important to note that men are more likely than women to have large growths at the point of diagnosis.
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Sentinel Lymph Node Biopsy And Other Procedures
In later stages of the disease, your healthcare provider may palpate the nearby lymph nodes for enlargement. If they are larger than is normal, the surgeon will remove them.
If lymph nodes are not enlarged, a sentinel lymph node biopsy may be used to detect the presence of metastasis . In this procedure, the surgeon removes a small sample of the nearest lymph nodes and sends it to a lab so it can be tested for cancer cells.
If metastasis is found, other forms of treatment may be necessary.