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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 13 | 7 | 20 |
| 2024 Octubre | 110 | 36 | 146 |
| 2024 Septiembre | 111 | 31 | 142 |
| 2024 Agosto | 123 | 56 | 179 |
| 2024 Julio | 122 | 37 | 159 |
| 2024 Junio | 125 | 39 | 164 |
| 2024 Mayo | 136 | 40 | 176 |
| 2024 Abril | 113 | 22 | 135 |
| 2024 Marzo | 94 | 22 | 116 |
| 2024 Febrero | 100 | 38 | 138 |
| 2024 Enero | 99 | 46 | 145 |
| 2023 Diciembre | 73 | 22 | 95 |
| 2023 Noviembre | 102 | 41 | 143 |
| 2023 Octubre | 129 | 33 | 162 |
| 2023 Septiembre | 111 | 46 | 157 |
| 2023 Agosto | 80 | 27 | 107 |
| 2023 Julio | 100 | 39 | 139 |
| 2023 Junio | 78 | 23 | 101 |
| 2023 Mayo | 112 | 30 | 142 |
| 2023 Abril | 99 | 28 | 127 |
| 2023 Marzo | 111 | 35 | 146 |
| 2023 Febrero | 99 | 34 | 133 |
| 2023 Enero | 82 | 34 | 116 |
| 2022 Diciembre | 88 | 38 | 126 |
| 2022 Noviembre | 38 | 33 | 71 |
| 2022 Octubre | 56 | 22 | 78 |
| 2022 Septiembre | 58 | 55 | 113 |
| 2022 Agosto | 65 | 41 | 106 |
| 2022 Julio | 56 | 45 | 101 |
| 2022 Junio | 63 | 35 | 98 |
| 2022 Mayo | 95 | 23 | 118 |
| 2022 Abril | 97 | 44 | 141 |
| 2022 Marzo | 62 | 68 | 130 |
| 2022 Febrero | 65 | 42 | 107 |
| 2022 Enero | 93 | 33 | 126 |
| 2021 Diciembre | 66 | 35 | 101 |
| 2021 Noviembre | 59 | 52 | 111 |
| 2021 Octubre | 80 | 65 | 145 |
| 2021 Septiembre | 69 | 28 | 97 |
| 2021 Agosto | 71 | 47 | 118 |
| 2021 Julio | 76 | 30 | 106 |
| 2021 Junio | 71 | 32 | 103 |
| 2021 Mayo | 52 | 43 | 95 |
| 2021 Abril | 178 | 54 | 232 |
| 2021 Marzo | 110 | 42 | 152 |
| 2021 Febrero | 86 | 26 | 112 |
| 2021 Enero | 51 | 22 | 73 |
| 2020 Diciembre | 53 | 19 | 72 |
| 2020 Noviembre | 53 | 24 | 77 |
| 2020 Octubre | 55 | 21 | 76 |
| 2020 Septiembre | 55 | 17 | 72 |
| 2020 Agosto | 42 | 15 | 57 |
| 2020 Julio | 58 | 17 | 75 |
| 2020 Junio | 45 | 36 | 81 |
| 2020 Mayo | 31 | 15 | 46 |
| 2020 Abril | 37 | 16 | 53 |
| 2020 Marzo | 38 | 19 | 57 |
| 2020 Febrero | 8 | 0 | 8 |
| 2020 Enero | 3 | 0 | 3 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 2 | 0 | 2 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 6 | 1 | 7 |
| 2019 Abril | 4 | 0 | 4 |
| 2019 Marzo | 4 | 0 | 4 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 3 | 0 | 3 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Marzo | 0 | 1 | 1 |
| 2018 Febrero | 32 | 3 | 35 |
| 2018 Enero | 50 | 8 | 58 |
| 2017 Diciembre | 71 | 16 | 87 |
| 2017 Noviembre | 50 | 8 | 58 |
| 2017 Octubre | 125 | 34 | 159 |
| 2017 Septiembre | 9 | 12 | 21 |
| 2017 Agosto | 1 | 5 | 6 |
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