Case and Research Letter
Amelanotic Subungual Melanoma Mimicking Telangiectatic Granuloma: Clinical, Histologic, and Radiologic Correlations
Melanoma amelanótico subungueal simulando granuloma telangiectásico. Correlación clínica, histológico y radiológica
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Silva-Feistner, E. Ortiz, S. Alvarez-Véliz, X. Wortsman" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Silva-Feistner" "email" => array:1 [ 0 => "marcos.silva.feistner@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Alvarez-Véliz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "X." "apellidos" => "Wortsman" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Pontificia Universidad Católica de Chile, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "IDIEP-Instituto de Investigación y Diagnóstico por Imágenes en Piel y Tejidos Blandos, Departamento Dermatología, Universidad de Chile, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Melanoma amelanótico subungueal simulando granuloma telangiectásico. Correlación clínica, histológico y radiológica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1231 "Ancho" => 1708 "Tamanyo" => 957501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology. Ulcerated amelanotic melanoma; Breslow depth, 3<span class="elsevierStyleHsp" style=""></span>mm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Subungual melanoma is uncommon and accounts for just 2% to 3% of all cutaneous melanomas. Less than 10% of subungual melanomas are amelanotic and 90% of these occur on the thumb or great toe. They typically appear in the seventh decade of life and are associated with a delayed diagnosis and a poor prognosis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–4</span></a> Amelanotic subungual melanoma generally manifests as a persistent vascular or ulcerated nodule. On ultrasound (US), subungual melanoma appears as a moderately well-defined hypoechoic area with increased thickness and decreased echogenicity of the nail bed, which frequently erodes into the bone margin of the distal phalanx, viewed as a hyperechoic structure pushing up and eroding into the bilaminar hyperechoic structure of the nail plate. Color Doppler US shows marked hypervascularization. Telangiectatic granuloma is the main entity to be considered in the differential diagnosis. This benign acquired vascular tumor is relatively common, and frequently affects the nail, the nail bed, and the periungual tissues.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> On US, subungual telangiectatic granuloma appears as a focal hypoechoic area with thickening and decreased echogenicity of the nail bed, which pushes up the nail plate but does not erode into the bone margin of the distal phalanx; hypervascularization is also observed.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Subungual melanoma requires a high index of clinical suspicion given its similarity to other conditions. We report on such a case evaluated at our department.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 67-year-old man presented with a fast-growing asymptomatic lesion of 1 month's duration on the nail of his left great toe. He reported bleeding following minor trauma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Physical examination revealed a friable subungual erythematous nodule with a vascular appearance associated with disruption of the nail plate. Color Doppler US showed increased thickness and a diffuse decrease in echogenicity of the nail bed. Diffuse hypervascularization of the nail bed was also observed. These findings were consistent with subungual inflammation associated with granulomatous changes predominantly affecting the central zone, suggesting a preliminary diagnosis of telangiectatic granuloma (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The lesion was surgically excised with wide margins, and the histologic evaluation showed nodular, ulcerated malignant melanoma of the nail bed, with a Clark level III, a Breslow depth of 3<span class="elsevierStyleHsp" style=""></span>mm, and a mitotic rate of 10 mitoses/mm<span class="elsevierStyleSup">2</span> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Amelanotic subungual melanoma generally manifests as a persistent vascular or ulcerated nodule. The differential diagnosis is broad and includes glomus tumor, squamous cell carcinoma, and, most importantly, telangiectatic granuloma.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,7,8</span></a> Some of the most main US characteristics that can help to distinguish between these conditions are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Clinically, subungual melanomas have a dull erythematous surface, while the majority of vascular tumors have a bright red surface.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> They also tend to bleed less and grow slowly, over the course of months or years, unlike telangiectatic melanoma, which typically grows in a matter of weeks. There may be a history of trauma in up to 25% of cases of subungual melanoma. The case of amelanotic subungual melanoma described in this report was difficult to diagnose by US, as it lacked well-defined borders and erosion of the bone margin of the distal phalanx, 2 common features of this tumor. In addition, the ability of US to detect pigment is currently limited.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A strong correlation has been reported between tumor thickness measured by color Doppler US and Breslow depth (histology) in cutaneous melanoma, and US is therefore a useful additional tool for investigating suspected cases of subungual melanoma. Although color Doppler US is used to study a wide variety of nail lesions, it has only been used in isolated cases of amelanotic subungual melanoma and none of the studies have used plain US.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Early studies reported 5-year survival rates of close to 16% for subungual melanoma, and even lower rates were described for patients who had undergone distal amputation at the metacarpophalangeal or metatarsophalangeal levels. Proximal amputation is thus the current treatment of choice.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Mohs micrographic surgery has also been proposed as a potentially interesting treatment for subungual melanoma. The drawback, however, is that it has been used in small series and more cases are needed to determine its effectiveness.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, amelanotic subungual melanoma is difficult to diagnose both clinically and sonographically. It is therefore essential to rule out other malignant or benign tumors and to perform an early biopsy. Amelanotic subungual melanoma can mimic subungual telangiectatic granulomas on US, particularly in the absence of erosion of the phalanx or nail plate.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:2 [ "identificador" => "xack303052" "titulo" => "Acknowledgments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Silva-Feistner M, Ortiz E, Alvarez-Véliz S, Wortsman X. Melanoma amelanótico subungueal simulando granuloma telangiectásico. Correlación clínica, histológico y radiológica. Actas Dermosifiliogr. 2017;108:785–787.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1422 "Ancho" => 1067 "Tamanyo" => 137833 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous subungual nodule.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1231 "Ancho" => 1708 "Tamanyo" => 957501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology. Ulcerated amelanotic melanoma; Breslow depth, 3<span class="elsevierStyleHsp" style=""></span>mm.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1219 "Ancho" => 1625 "Tamanyo" => 208173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Color Doppler ultrasound (18<span class="elsevierStyleHsp" style=""></span>Hz) of the nail unit.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lesion \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Echogenicity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Borders \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nail Plate Erosion \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bone Remodeling<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bone Erosion<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hypervascularization \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ungual melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypoechoic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poorly defined \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>+<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>+<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Telangiectatic granuloma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypoechoic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poorly defined \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glomus tumor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypoechoic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Well defined \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Squamous cell carcinoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypoechoic or heterogeneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poorly defined \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>+<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+<span class="elsevierStyleHsp" style=""></span>+<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1527678.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Bone remodeling involves change to the relief or convexity of the distal phalanx without interruption of the cortex. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 7 | 20 |
| 2024 October | 110 | 36 | 146 |
| 2024 September | 111 | 31 | 142 |
| 2024 August | 123 | 56 | 179 |
| 2024 July | 122 | 37 | 159 |
| 2024 June | 125 | 39 | 164 |
| 2024 May | 136 | 40 | 176 |
| 2024 April | 113 | 22 | 135 |
| 2024 March | 94 | 22 | 116 |
| 2024 February | 100 | 38 | 138 |
| 2024 January | 99 | 46 | 145 |
| 2023 December | 73 | 22 | 95 |
| 2023 November | 102 | 41 | 143 |
| 2023 October | 129 | 33 | 162 |
| 2023 September | 111 | 46 | 157 |
| 2023 August | 80 | 27 | 107 |
| 2023 July | 100 | 39 | 139 |
| 2023 June | 78 | 23 | 101 |
| 2023 May | 112 | 30 | 142 |
| 2023 April | 99 | 28 | 127 |
| 2023 March | 111 | 35 | 146 |
| 2023 February | 99 | 34 | 133 |
| 2023 January | 82 | 34 | 116 |
| 2022 December | 88 | 38 | 126 |
| 2022 November | 38 | 33 | 71 |
| 2022 October | 56 | 22 | 78 |
| 2022 September | 58 | 55 | 113 |
| 2022 August | 65 | 41 | 106 |
| 2022 July | 56 | 45 | 101 |
| 2022 June | 63 | 35 | 98 |
| 2022 May | 95 | 23 | 118 |
| 2022 April | 97 | 44 | 141 |
| 2022 March | 62 | 68 | 130 |
| 2022 February | 65 | 42 | 107 |
| 2022 January | 93 | 33 | 126 |
| 2021 December | 66 | 35 | 101 |
| 2021 November | 59 | 52 | 111 |
| 2021 October | 80 | 65 | 145 |
| 2021 September | 69 | 28 | 97 |
| 2021 August | 71 | 47 | 118 |
| 2021 July | 76 | 30 | 106 |
| 2021 June | 71 | 32 | 103 |
| 2021 May | 52 | 43 | 95 |
| 2021 April | 178 | 54 | 232 |
| 2021 March | 110 | 42 | 152 |
| 2021 February | 86 | 26 | 112 |
| 2021 January | 51 | 22 | 73 |
| 2020 December | 53 | 19 | 72 |
| 2020 November | 53 | 24 | 77 |
| 2020 October | 55 | 21 | 76 |
| 2020 September | 55 | 17 | 72 |
| 2020 August | 42 | 15 | 57 |
| 2020 July | 58 | 17 | 75 |
| 2020 June | 45 | 36 | 81 |
| 2020 May | 31 | 15 | 46 |
| 2020 April | 37 | 16 | 53 |
| 2020 March | 38 | 19 | 57 |
| 2020 February | 8 | 0 | 8 |
| 2020 January | 3 | 0 | 3 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 2 | 0 | 2 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 6 | 1 | 7 |
| 2019 April | 4 | 0 | 4 |
| 2019 March | 4 | 0 | 4 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 3 | 0 | 3 |
| 2018 March | 0 | 1 | 1 |
| 2018 February | 32 | 3 | 35 |
| 2018 January | 50 | 8 | 58 |
| 2017 December | 71 | 16 | 87 |
| 2017 November | 50 | 8 | 58 |
| 2017 October | 125 | 34 | 159 |
| 2017 September | 9 | 12 | 21 |
| 2017 August | 1 | 5 | 6 |
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