Background: Acral Lentiginous Melanoma (ALM) occurs in nailbeds and glabrous skin of the hands and feet. While uncommon (2-3% of melanoma) ALM is often advanced at diagnosis and demonstrates lower response rates to adjuvant therapies. Amputation of ALM affected digits is current recommended management but results in significant functional impairment. Emerging evidence supports wide local excision (WLE) with digit preserving surgery (DPS) in the hand.
Methods: A retrospective review was performed of all patients treated with DPS at our institution in 2022. Outcomes included excision margins, wound healing time, functional recovery at 3 months and recurrence at 6 months.
Results: Five patients had DPS (3 female, mean age 60yrs). Breslow thickness ranged from in-situ to 1.3mm. Sentinel lymph node biopsy was performed in 2 patients, both negative. 10mm margins for invasive and 5mm for in-situ ALM were taken. Deep margin control included removal of partial thickness distal phalanx in two cases. Reconstruction with full thickness skin grafts had a 100% take rate (5/5). Tip hypersensitivity occurred initially, but responded well to hand therapy. One patient had stiffness at 3 months related to other comorbidities, the rest had full range of motion by 3 months. There was no evidence of locoregional recurrence at 6 months.
Conclusion: DPS for ALM of the hand provides adequate surgical margins, excellent functional outcomes, and no evidence of locoregional recurrence in early follow-up. Digit preservation should be considered as part of the management options for in-situ and thin melanomas of functionally important digits affected by ALM. Further study with a prospective clinical trial is planned.