Controversies in acral lentiginous melanoma.
Stalkup Jennifer R,Orengo Ida F,Katta Rajani
Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]
BACKGROUND:Acral lentiginous melanoma (ALM) is a subtype of melanoma initially described only two and half decades ago, but well-recognized by dermatologists today. However, several areas of controversy surround this entity. OBJECTIVE:The primary aims of this article are to review the literature, highlight recent advances, and review some of the ongoing controversies in ALM. METHODS:A review of the English language literature was performed. RESULTS:Controversy continues to surround ALM, particularly in regard to diagnostic histologic and clinical criteria. This leads to difficulties when reviewing studies that evaluate the epidemiology, etiology, and prognosis of ALM. CONCLUSION:Progress in understanding ALM requires the development of standardized diagnostic criteria.
Dermoscopic patterns of acral melanocytic lesions in skin of color.
Tan Andrea,Stein Jennifer A
Acral lentiginous melanoma (ALM) is a rare but aggressive subtype of melanoma often associated with poor prognosis. Although overall incidence is rare, ALM accounts for a larger proportion of melanomas among black, Asian, and Hispanic individuals than among white individuals. Similarly, the proportion of acral melanocytic nevi tends to be greater in ethnic skin despite a lower overall nevi count. Dermoscopy can help differentiate between benign and malignant acral melanocytic lesions. Herein, we discuss the population trends of acral melanocytic lesions in patients with skin of color. We also examine the diagnostic challenges of acral lesions and review the dermoscopic patterns unique to acral volar skin.
Sequential acral lentiginous melanomas of the foot.
Uehara Jiro,Ito Yasuhiro,Takahashi Ichiro,Honma Masaru,Ishida-Yamamoto Akemi,Matsuo Shinobu,Iizuka Hajime
Case reports in dermatology
A 64-year-old Japanese woman had a lightly brown-blackish pigmented macule (1.2 cm in diameter) on the left sole of her foot. She received surgical excision following a diagnosis of acral lentiginous melanoma (ALM), which was confirmed histopathologically. One month after the operation, a second melanoma lesion was noticed adjacent to the grafted site. Histopathologically, the two lesions had no continuity, but HMB-45 and cyclin D(1) double-positive cells were detected not only on aggregates of atypical melanocytes but also on single cells near the cutting edge of the first lesion. The unique occurrence of a sequential lesion of a primary melanoma might be caused by stimulated subclinical field cells during the wound healing process following the initial operation. This case warrants further investigation to establish the appropriate surgical margin of ALM lesions.
Acral Melanoma in Chinese: A Clinicopathological and Prognostic Study of 142 cases.
Lv Jiaojie,Dai Bo,Kong Yunyi,Shen Xuxia,Kong Jincheng
Acral melanoma (AM), as a peculiar subgroup of melanoma, is rare in Caucasians but has higher incidence in Asians. Large series of study on AM with clinicopathological features and prognostic factors is still limited, especially in Asian population. We retrospectively collected clinical, pathological and follow-up data of 142 AM cases. All patients were Chinese, with the age ranging from 24 to 87 years (mean 62.0; median 62.0). The Breslow thickness of primary lesions ranged from 0.6 to 16.3 mm (mean 4.9; median 3.7). 85.9% of the patients had acral lentiginous histologic subtype. Plantar was the most frequently involved site, followed by heels. Statistically, duration of the lesion before diagnosis (≤2.5 years), Breslow thickness >4.0 mm (T4), high mitotic index (>15 mm(-2)), presence of vascular invasion, regional lymph node metastasis at diagnosis and pathologic stage (II/III/IV) were found to be independent prognostic factors in both univariate and multivariate analyses. The prognosis of AM in Chinese is extremely poor. Our 5- and 10-year disease-specific survival (DSS) rates were 53.3% and 27.4%, respectively. Therefore, AM in Asians represents a more biologically aggressive melanoma subtype and is thought to carry a worse prognosis when compared with other races or cutaneous melanomas in other anatomic sites.
Conservative surgical treatment of a thin acral lentiginous melanoma of the thumb with no recurrences: a case report.
Proietto Gianluca,Giaculli E,De Biasio F,Guarneri G F,Rampino Cordaro E,Parodi P C
Surgical treatment for acral lentiginous melanoma (ALM) is usually radical and severely invalidating, given its distinctly aggressive nature and poor prognosis. We report on a 76-year-old male patient with ALM of the left thumb who refused total amputation that would limit his gripping function. A "surgical degloving" was consequently performed, followed by plastic reconstruction with a radial antebrachial (the so-called Chinese) flap. A year after surgery, the patient was able to perform most finalized thumb movements without difficulty, and no metastases were recorded over a 5-year follow-up. The authors discuss the indications for such a treatment for thinner ALM in relation to the biological behavior of ALM.
Clinical presentation of acral lentiginous melanoma: a descriptive study.
Pereda C,Traves V,Requena C,Serra-Guillén C,Llombart B,Sanmartín O,Guillén C,Nagore E
BACKGROUND AND OBJECTIVE:Acral lentiginous melanomas -the melanomas most commonly found on the distal portions of the limbs- have usually reached more advanced stages than other types of melanoma when diagnosed. Our aim was to describe the clinical presentation of these tumors. MATERIALS AND METHODS:Retrospective, descriptive, observational study of cases recorded in the database of the Instituto Valenciano de Oncología. In telephone interviews the patients answered a questionnaire on the presenting features of the lesion, on the presence of signs and symptoms included in the Glasgow 7-point checklist and the ABCDEs of melanoma, and on diagnostic delay attributable to patient or physician. RESULTS:In the interviews with the 23 patients who responded to the questionnaire, we detected a diagnostic delay of more than 1 year attributable to the patient (delay in seeking care) in 30.4% of the cases. Diagnostic delay of more than 1 year attributable to the physician (failure to suspect the diagnosis) was identified in 20%. The most frequent reasons for consulting a physician about a lesion were changes in size, changes in color, bleeding, or failure to heal. In 20% of the cases the evaluating physician did not order histology for over a year. CONCLUSIONS:Diagnostic delay is a significant problem in acral lentiginous melanoma and may be attributable either to patients or to physicians' failure to recognize warning signs. Melanoma prevention campaigns should place more emphasis on the possibility of melanomas appearing on the palms and, particularly, on the soles.
Acral lentiginous melanoma of the foot misdiagnosed as a traumatic ulcer. A cautionary case.
Gumaste Priyanka,Penn Lauren,Cohen Nicole,Berman Russell,Pavlick Anna,Polsky David
Journal of the American Podiatric Medical Association
The incidence of cutaneous melanoma is rising faster than that of almost any other cancer in the United States. Acral lentiginous melanoma is a subtype of melanoma that involves the palms, soles, and nail beds. Although it is one of the rarer types of melanoma, it has a poorer prognosis than other more common subtypes. We describe a case of plantar acral melanoma in a 66-year-old woman that was initially misdiagnosed as a traumatic foot ulcer. We highlight this case to emphasize the importance of close observation and biopsy of ulcerative lesions of the foot that have atypical features or are refractory to standard treatment.
Rare cause of non-healing foot wound--acral lentiginous melanoma.
Gerslova Alena,Pokorna Andrea,Stukavcova Alena,Veverkova Lenka
Neuro endocrinology letters
The etiology of skin integrity disorders of the lower extremities can be very diverse. In addition to common diagnoses such as venous ulcers with ischemic etiology, decubitus ulcers and diabetic foot syndrome, ulceration of a malignant etiology must also be considered. Malignant melanoma is one of the most dangerous forms of skin cancer and, although rare, may cause foot lesions. The most frequently encountered type of melanoma on acral parts of the limbs is the rare acral lentiginous variant, which only occurs in 2-10% of all melanoma types. Clinical manifestation ranges from cutaneous surface erosion to ulceration with surrounding hyperkeratosis, which can cause considerable differential diagnostic difficulties in the management of patients with non-healing foot wounds. This paper aims to present a clear case study of a Caucasian female with chronic leg ulceration that resulted in a final diagnosis of malignant acral lentiginous melanoma. Supplemental theoretical information regarding the diagnosis and treatment of malignant melanoma has also been included in the report. Malignant acral lentiginous melanoma is a rare cause of non-healing wounds, but it must be considered in cases with long-term healing complications. Precise diagnostic deliberation is crucial in the management and treatment of all chronic and long-term non-healing lesions, and appropriately performed biopsies are essential to determine whether malignancy is the primary cause.
Acral lentiginous melanoma: Basic facts, biological characteristics and research perspectives of an understudied disease.
Basurto-Lozada Patricia,Molina-Aguilar Christian,Castaneda-Garcia Carolina,Vázquez-Cruz Martha Estefania,Garcia-Salinas Omar Isaac,Álvarez-Cano Alethia,Martínez-Said Héctor,Roldán-Marín Rodrigo,Adams David J,Possik Patricia A,Robles-Espinoza Carla Daniela
Pigment cell & melanoma research
Acral lentiginous melanoma is a histological subtype of cutaneous melanoma that occurs in the glabrous skin of the palms, soles and the nail unit. Although in some countries, particularly in Latin America, Africa and Asia, it represents the most frequently diagnosed subtype of the disease, it only represents a small proportion of melanoma cases in European-descent populations, which is partially why it has not been studied to the same extent as other forms of melanoma. As a result, its unique genomic drivers remain comparatively poorly explored, as well as its causes, with current evidence supporting a UV-independent path to tumorigenesis. In this review, we discuss current knowledge of the aetiology and diagnostic criteria of acral lentiginous melanoma, as well as its epidemiological and histopathological characteristics. We also describe what is known about the genomic landscape of this disease and review the available biological models to explore potential therapeutic targets.
Early detection of acral melanoma: A review of clinical, dermoscopic, histopathologic, and molecular characteristics.
Darmawan Claudia C,Jo Gwanghyun,Montenegro Sara E,Kwak Yoonjin,Cheol Lee,Cho Kwang Hyun,Mun Je-Ho
Journal of the American Academy of Dermatology
Acral lentiginous melanoma is a distinct subtype of melanoma on acral skin. Patient presentation at later stages and delayed diagnosis by physicians contribute to a worse associated prognosis and survival rate. Despite our progress in understanding the key features of this disease, the diagnosis of early-stage acral melanoma is still challenging. It is essential to integrate clinical, dermoscopic, and histologic findings in the diagnosis of acral lentiginous melanoma. In addition, molecular studies can be helpful. In this review, we have summarized our current understanding of this disease entity from articles that were published between 1969 and 2018. We have outlined clinical and dermoscopic features as well as pathologic and molecular findings regarding acral melanoma and have presented an algorithm for diagnosis. Understanding and integrating these characteristics may assist clinicians in the early detection of acral melanomas.
Acral Lentiginous Melanoma.
Goydos James S,Shoen Steven L
Cancer treatment and research
Acral lentiginous melanoma (ALM) is a rare subtype of melanoma mainly arising on the palms, soles, and nail beds. ALM is the most common subtype of melanoma found in patients of Asian or African descent and tends to more advanced at presentation due to delays in diagnosis. Surgical treatment is difficult owing to the complexity and functional importance of the hands and feet and reconstruction after resection is usually needed. The prognosis for patients with ALM depends on stage of disease and tends to be worse than with other subtypes of melanoma. Newer treatment modalities such as immunotherapies and targeted agents are being tested in patients with advanced ALM with some promising preliminary results.
The Misdiagnosis of Acral Lentiginous Melanoma: Three Case Presentations.
Markinson Bryan C,Stowers Jered M,Black Alexandra,Saccomanno Rosario,Desman Garrett
Journal of the American Podiatric Medical Association
Acral lentiginous melanoma (ALM) is a disease that is found on the palms, soles, and nail beds. Because these areas are not often examined during general medical examinations, the presence of ALM often goes unnoticed or the diagnosis is delayed. Research shows that the misdiagnosis of ALM is common, reported between 20% and 34%. We present three cases of ALM that were initially misdiagnosed and referred to the senior author (B.C.M.) in an effort to assess why misdiagnosis is common. The existing literature illuminates clinical pitfalls in diagnosing ALM. The differential diagnosis of many different podiatric skin and nail disorders should include ALM. Although making the correct diagnosis is essential, the prognosis is affected by the duration of the disease and level of invasiveness. Unfortunately, most of the reported misdiagnosed cases are of a later stage and worse prognosis. This review highlights that foot and ankle specialists should meet suspect lesions with a heightened index of suspicion and perform biopsy when acral nonhealing wounds and/or lesions are nonresponsive to treatment.
Acral Lentiginous Melanoma: A Rare Variant With Unique Diagnostic Challenges.
Brazen Brett C,Gray Taylor,Farsi Maheera,Miller Richard
Acral lentiginous melanoma (ALM), named for its location and histological growth pattern, is a rare variant of melanoma. ALM presents on palms, soles, or in association with the nail unit. While ALM accounts for approximately 5% of melanomas diagnosed each year, it is the most commonly diagnosed subtype of melanoma in non-Caucasian patients, and it is most likely to be diagnosed in the seventh decade of life. We present a case of a 72-year-old, Fitzpatrick skin type (FST) 5 female who presented to our clinic with a chief complaint of a slowly enlarging dark brown patch with a variation of pigment changes that had been present for 10 years on her right plantar surface. Biopsy obtained for hematoxylin and eosin (H&E) revealed malignant melanoma in situ, acral lentiginous type. Here, we will discuss the unique pathogenesis of ALM, as well as, its characteristic clinical and histological findings. Furthermore, this case underscores the importance of physician and patient education to raise awareness of this rare type of melanoma, specifically in patients with skin of color in hopes of decreasing time to diagnosis and improving prognosis.
High density of M2-macrophages in acral lentiginous melanoma compared to superficial spreading melanoma.
Zúñiga-Castillo Miguel,Pereira Naiura V,Sotto Mirian N
AIMS:Acral lentiginous melanoma (ALM) is the most common type of melanoma in people with darker skin phototypes. There is some evidence that the aetiology, pathogenesis, risk factors and natural history of ALM differ from those of superficial spreading melanoma (SSM). ALM behaves more aggressively than SSM, but the biological explanation for these differences remains unknown. The presence of one subtype of macrophages, termed M2-macrophage (M2-M), has been found to be related to local progression, metastasis and poor prognosis in several neoplasms. The aim of this study was to compare the density of M2-Ms in ALMs versus SSMs, and to examine whether or not the density of M2-Ms is associated with histopathological features predictive of adverse prognosis in cutaneous melanoma (CM), as well as development of metastasis. METHODS AND RESULTS:Sixty-seven ALMs and 67 SSMs cases were analysed. The tumours were classified according to thickness, ulceration, mitosis and metastasis. M2-M quantity was evaluated using immunohistochemistry with anti-CD163 and anti-CD206 antibodies. M2-Ms were increased in ALM compared with SSM, and were related to the histopathological features predictive of adverse prognosis in CM, such as thickness > 1.0 mm, ulceration and mitotic activity, and the development of metastasis. CONCLUSIONS:Our study is the first, to our knowledge, to demonstrate the increased presence of M2-Ms in ALM compared with SSM. Our findings suggest that the increased M2-Ms in ALM are associated with the main histopathological features predictive of adverse prognosis in CM, as well as the presence of metastasis, and that these cells can be related to the aggressive behaviour seen in ALMs.
Acral Lentiginous Melanoma, Indolent Subtype Diagnosed by Excision: A Case Report.
Ohn Jungyoon,Bae Jeong Mo,Lim Ji Soo,Park Jong Seo,Yoon Hyun-Sun,Cho Soyun,Park Hyun-Sun
Annals of dermatology
Nail unit melanoma is a type of acral lentiginous melanoma and requires histopathologic examination for a confirmed diagnosis. However, inadequate biopsy techniques make definitive diagnosis difficult. A 61-year-old man presented with progressive nail pigmentation for 15 years, which was clinically highly suspicious for malignancy. Acral lentiginous melanoma was not detected in punch and longitudinal biopsy specimens, but excision tissue revealed melanoma. Acral lentiginous melanoma is known to have a heterogeneous pathologic manifestation depending on the pigmented region and the time it takes to progress. In this regard, excision can be considered as a first-line biopsy technique to diagnose acral lentiginous melanoma, indolent subtype.
Acral Lentiginous Melanoma of Foot and Ankle: A Clinicopathological Study of 7 Cases.
Hao Xingpei,Yim Joon,Chang Stewart,Schwartz Erika,Rubenstein Seth,Friske Casey,Shamim Sana,Masternick Eric,Mirkin Gene
BACKGROUND/AIM:Acral lentiginous melanoma (ALM) is a rare entity on the foot. This study aimed to reveal its clinical presentations, histopathology and treatment options. MATERIALS AND METHODS:Seven cases of ALM involving foot were treated in our Institute in a 3-year period. RESULTS:The patients' age ranged from 38 to 84 years, with a mean of 65. The ratios of males to females and white to non-white were 4:3 and 5:2, respectively. Clinically, ALM presented as asymmetric, irregular shaped, black-brown, variegatedly discolored, papular, verrucoid, ulcerated or nodular lesions with or without pain. All ALMs were treated with either wide local excision (WLE) or toe amputation. Histologically, ALM was characterized by multiple single and nested atypical melanocytes growing along the dermal-epidermal junction, and extending into dermal layer in nodular growth pattern. CONCLUSION:ALM is a rare, asymmetric, irregularly bordered, variegatedly pigmented lesion. WLE or toe amputation is the standard treatment option.
Diagnosis and Management of Acral Lentiginous Melanoma.
Nakamura Yoshiyuki,Fujisawa Yasuhiro
Current treatment options in oncology
OPINION STATEMENT:Melanoma is one of the most aggressive malignant skin tumors and its incidence has been increasing worldwide in recent decades. Among the four subtypes, acral lentiginous melanoma (ALM) shows the highest incidence in Asian countries, whereas ALM comprises only 1% of all melanomas in white populations. Early clinical diagnosis of ALM is essential, but early ALM lesions are often difficult to diagnose because the pigmentation of the lesions sometimes follows the skin marking of the palms and soles, resulting in an asymmetrical appearance and an irregular border in both ALM and benign melanocytic nevus. To overcome this difficulty, dermoscopy was introduced, and determination of the patterns by this method is essential for accurate clinical diagnosis of ALM. Although recent clinical trials have demonstrated that immune checkpoint inhibitors and BRAF/MEK inhibitors showed significantly improved overall survival of patients with advanced melanoma, ALM may be less susceptible to immune checkpoint inhibitors because of the poor immune response to the tumor. Therefore, strategies for enhancing the immune response to the tumor cells may be required when we apply immune checkpoint inhibitors in advanced ALM. In this context, imiquimod, dacarbazine, or interferon are possible therapies that may enhance the effectiveness of the immune checkpoint inhibitors. In addition to being known to have poor immunogenicity, ALM is also known to have infrequent BRAF mutation. Therefore, the majority of ALM patients may not benefit from therapy with BRAF/MEK inhibitors. However, some ALMs have mutations such as KIT and NRAS mutations, and therefore, targeted therapies may improve the survival of ALM patients in the future.
Histopathological diagnosis of acral lentiginous melanoma in early stages.
Fernandez-Flores Angel,Cassarino David S
Annals of diagnostic pathology
Acral lentiginous melanoma is a rare variant of melanoma that is associated with a relatively low survival rate. The latter is partly due to the advanced stage in which the tumor is usually diagnosed. The diagnostic delay is mainly due to difficulties in identifying the very early histopathological signs of acral melanoma. The current article is a review of diagnostic clues, concepts, and definitions from the literature, as well as illustrating examples from our own archives. We have sought to provide an article that can be easily consulted in difficult cases of acral lentiginous melanoma.
National Comprehensive Analysis of Characteristics of Acral Lentiginous Melanoma.
Huayllani Maria T,Restrepo David J,Boczar Daniel,Avila Francisco R,Bagaria Sanjay P,Spaulding Aaron C,Rinker Brian D,Forte Antonio J
BACKGROUND/AIM:Acral lentiginous melanoma (ALM) is the least common subtype of cutaneous melanoma and typically occurs on the palms, soles, and nails. Tumor characteristics and disease severity in the US population are not well understood. Our aim was to analyze the characteristics of ALM of the extremities. PATIENTS AND METHODS:We queried the National Cancer Database to identify patients with the diagnosis of ALM and common malignant melanoma located in the extremities (CMME). We compared demographic, tumor, and treatment characteristics between patients with ALM and those with CMME. Statistical analysis was performed with chi-squared test and multivariate logistic regression models. RESULTS:We identified 5,203 patients with ALM and 118,485 with CMME. When compared with patients with CMME, those with ALM were more likely to be older than 80. years at diagnosis [odds ratio (OR)=2.85, 95% confidence intervaI (CI)=2.12-3.82; p<0.001], have stage III disease (OR=4.22, 95% CI=1.47-12.16; p=0.01), and have ulceration (OR=1.52, 95% CI=1.33-1.74; p<0.001). Moreover, patients with ALM were less likely to have a mitotic count of 1/mm or greater (OR=0.57, 95% CI=0.48-0.67; p<0.001). No statistical difference was found for sex, lymph node involvement, regression, and use of surgery, radiotherapy, and immunotherapy between groups. CONCLUSION:Age, disease stage, ulceration, and mitotic count are independent factors associated with ALM. Knowledge of the disease characteristics may allow for better diagnosis and understanding of disease pathophysiology.