SURGICAL-MANAGEMENT OF PRIMARY CUTANEOUS MELANOMAS OF THE HANDS AND FEET

Objective The purpose of the study was to investigate the surgical man agement of cutaneous melanomas of the hands and feet. Summary Backgrou nd Data Prior studies suggest that patients with melanomas >1-mm thick should be treated with excision with a 2-cm margin and undergo electi ve lymphadenectomy in selected circumstances. These recommendations ar e based primarily on data from melanomas of the trunk and extremities. Melanomas of the hands and feet are less common and less well studied . They pose a surgical challenge because primary wound closure often i s difficult, and the incidence and management of regional node metasta ses are unclear. Methods Charts of patients with melanomas of the hand s or feet treated at the Massachusetts General Hospital between 1980 a nd 1994 were reviewed retrospectively. Local recurrence rates and the incidence of regional node metastases were analyzed as a function of h istology, margin of excision, and microscopic thickness of the melanom a. Results Data from 116 patients (39 men, 77-women) with melanomas of the hands (n = 26) and feet (n = 90) were evaluated. Pathologic diagn oses were: acral lentiginous melanoma (48 patients); subungual melanom a (13 patients), and skin of dorsum of the hand or foot (n = 55). Digi tal amputation was required in all 13 patients with subungual melanoma to maintain local control; still, nodal metastases developed in 46% o f patients within 1 year. Seventy-one percent of patients with acral l entiginous melanoma presented with lesions greater than or equal to 1. 5 mm, and nodes or systemic disease or both developed in 56% of patien ts. Acral lentiginous melanoma lesions <1.5-mm thick were treated prin cipally by excision with a 1cm margin; a local recurrence or metastase s did not develop in any of the patients. None of the patients with me lanomas on the dorsum of the hand or foot <1.5-mm thick had a local re currence, but regional or systemic disease developed in >50%. Local co ntrol in patients with lesions >1.5-mm thick frequently required skin grafting or amputation. The majority of patients with melanomas>1.5 mm in thickness undergoing elective lymph node dissection had histologic ally positive nodes for melanoma. Conclusions Melanomas of the hands a nd feet <1.5-mm thick have a low incidence of nodal metastases and are treated effectively with wide excision of the primary with a I-cm mar gin. Thicker melanomas are associated with a >50% rate of regional or systemic failure. In the absence of metastatic disease, these individu als should undergo local excision with a 2-cm margin and intraoperativ e lymphatic mapping followed by lymphadenectomy if the sentinel node i s positive.