Nail tumor after mechanical trauma

Received on: 10 February 2012
Approved on: 01 March 2012

This study was carried out at the
Dermatology Department of the Internal
Medicine, Geriatric Diseases and Nephrology
at the University of Bologna, Bologna, Italy.

Financial support: None
Conflicts of interest: None

Abstract

This article describes the case of a 62-year-old patient who developed an erosive nodular mass on the nail apparatus after receiving a trauma during a hunting incident. The lesion was initially diagnosed as an amelanotic melanoma of the nail apparatus, illustrating the fact that this type of lesion is often misdiagnosed – up to 85% of the time if the physician lacks dermatological expertise –and remains untreated for prolonged periods.

Keywords: MELANOMA, MELANOMA, AMELANOTIC, WOUNDS AND INJURIES

A 62-year-old male was referred to us with a 20-year his- tory of a nodular, ulcerated mass on the 2nd finger of the left hand. The patient, a professional lifeguard in Marina di Ravenna, was otherwise healthy.

The mass had developed as a slowly growing nodule, the result of a hunting injury that had received multiple treatments over the years. The last therapy the patient went through befo- re his visit to us was hyperbaric oxygen.

The lesion presented as a 2.5 × 1.7 cm highly vascularized ulcerated mass, covered with a mix of fibrotic and necrotic tis- sue (Figure 1).

Since an x-ray of the finger showed bone resorption, a nail bed biopsy was performed. The histopathologic results of the biopsy (Figure 2) revealed a tumor composed of cells with abundant eosinophilic cytoplasm, pleomorphic nuclei, promi- nent nucleoli, and abundant atypical mitotic figures infiltrating the surrounding soft tissues and the distal phalanx. Immunostaining for S-100 protein was positive, while Melan-A, HMB-45, CD 34, desmin, and myogenin were negative . A distal phalanx disarticulation was performed, and amelano- tic melanoma with ulceration was diagnosed, with an estimated 3.1 mm Breslow depth (40; N0 M0).

The patient underwent lymph node sentinel biopsy and a whole body CT scan examination, with negative results for metastases or other locations of the disease. Twelve months after the diagnosis, the patient developed auxiliary node recurrences (40; N1; M0) and underwent auxiliary dissection. Adjuvant interferon therapy followed, with good tolerance of the drug.

Amelanotic nail apparatus melanoma (NAM) is often mis- diagnosed and left untreated for prolonged periods of time. In fact, misdiagnosis rates are reported to be as high as 85% in the case of non-Dermatologist physicians. 3 Because of this delay, the survival rate of patients with NAM is significantly lower than that for other forms of melanoma, decreasing from an 80% 5-year survival rate at other sites to a 10-30% 5-year survival rate for NAM. 1,3

We do not know, in this particular case, whether the mela- noma developed in traumatized tissue or if the trauma – as reported by the patient – was unrelated. Trauma is considered a predisposing factor for the development of NAM, since the tumors are more common in the fingers most subjected to trau- mas, and the patient''''''''s history often refers to a trauma preceding the development of the lesion. 4 However, there are no data that prove the role of trauma in the development of NAM. As a mat- ter of fact, NAM may develop before the trauma, thus produ- cing a weaker nail that is less resistant to mechanical injuries. A study of 33 cases of nail melanoma could not confirm the influence of trauma on its primary pathogenesis, but concluded that trauma to the clinically apparent tumor was a significant prognostic factor for both recurrence-free survival and overall survival. 5

Moreover, our patient had been treated with hyperbaric oxygen therapy during the year before the melanoma was diag- nosed. Some studies report that hyperbaric oxygen might have cancer growth enhancing effects that lead to the proliferation of malignant cells and angiogenesis in a malignant tumor; 6 others contradict this hypothesis. 7

We also wondered whether surgical trauma due to biopsy may have worsened our patient''''''''s prognosis, since his NAM remained dormant – without metastases – for many years, and only started to metastasize after surgery. Recent studies, howe- ver, suggest that incisional biopsies of malignant melanomas do not negatively influence prognosis; they are currently recom- mended for the histopathologic diagnosis of tumors in acral locations. 8

In conclusion, clinicians should remember that an erosive nodular mass in the nail may be an amelanotic melanoma, and since early diagnosis is essential for a good prognosis, 1 a timely biopsy should be performed.

References

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