Dr. Frederick Fish outlines how to obtain a pathologic specimen from the sometimes difficult location of the peri and subungual region.
Welcome back and hopefully you had a successful break and were able to learn with some of the exhibitors. We want to move along and look at perhaps how uh we look at various digits and nails. And so we need to look at the evaluation of melon Nicaea dr fred fish, who is the most surgeon at Associated Skincare specialist. It is also uh at the University of Minnesota Hospital and fred completed his fellowship here with us a number of years ago and fred thanks for joining us again this year. Always a pleasure. It's more of a pleasure to be in san Diego than in Minnesota for the meeting but it's always a pleasure. Thank you for putting it on inviting me. Well next year we hope you'll be here in person. So I'm going to talk a little bit about the evaluation of milana Nicaea. Uh This is something we don't see a whole lot but it's an interesting thing that has uh some interesting aspects. And I want to thank dr Weinig and also my subscribe anna Steinhaus for helping me put this together. I have no disclosures. So we're going to talk a little bit about the definition of Melanie Kia and discuss benign versus malignant clinical presentations. Review causes of nail pigmentation that can clinically appear similar to Melania and review and compared Durmus coptic findings of Melania and Children and adults and discuss surgical techniques for diagnosis and in some cases treatment of Monica and then review some literature on sub angle atypical indigenous Molina city proliferations and Children and adolescents and also discuss nail apparatus melanoma and its relationship to Monica and then view kind of important differences between Melanie Kia and adults and Children. So defining malarkey is defined as a brown or black pigmentation on a nail as a result of melanin pigment. Here's a nice drawing of the nail plate nail bed And Milana sites typically occur in the Nail Matrix. The melanocytes in the more distal part of the matrix don't tend to our worthy about 50% uh dormant and 50% active. And this is where most of the milan acidic proliferations come from. They don't really come from the proximal nail matrix very much because most of melanocytes there are are all dormant. Then the nail bed doesn't have very many melanocytes in it. But often a melancholic melanoma will rise in the nail bed. So that's something to keep in mind. And general pigmented lesions that do not involve the nail metrics or fold or probably not milan acidic and origin. So here's some examples of a child and an adult with Melanie Kia Strada or a lion pigment extending from the proximal nail fold to the distal nail plate. And and Children about 30% of Longitudinal Monica is caused by melancholic molecules, whereas only 9% of adults Melanie Kia striated or London to Melania is caused by melancholic molecules Milan acidic nearby are more common in Children. The cost. About 48 Of Melon, acidic longitudinal streaking in the nail and adults, about 12% of those lesions nearby. So what is the importance of Melanie ca one of the most significant things is that Melanie Kia is associated with nail plate melanomas and about 38-76% of the time, which is kind of a large range. But anyway, it's a fairly common finding in melanoma of the nail plate. And so that's probably one of the most important things about it and having to determine whether it's associated with melanoma or not in each patient you evaluate. So I want to review a little bit of the causes of nail pigmentation which can look like Melanie Kia, but or not. So, so bungle hematoma is probably one of the most common causes of nail pigmentation or pigmentation under the nail plate. If you look to the right here, you can see that the nail plate is growing forward and the pigmentation is not present where the new nail is growing and that's a pretty good sign when you see that, that you don't have a pigmented lesion growing from the proximal nail full or the nail fold area forward, trauma can also cause pigmentation of the nails. And here's some trauma induced pigmentation along that toe which is curled down. We need to also think about systemic disease causing nail pigmentation. Splinter hemorrhages can be associated with endocarditis. However, by far the most common cause of splinter hemorrhages as trauma and fungus fungal disease can cause Melanie key here is an example of fungal mela Nicaea in a nail. Okay. And then bacterial infections especially pseudomonas can produce pigments that could be green and kind of dark green to black, that can mimic Melanie Kia. And then nail plate tumors such as nail uh matrix nevis is a common for our cause of melon icky. And here you can see that there's a little bit of pseudo Hutchinson sign here where you have a little bit of pigment seen within the cuticle. That is a rare tumor called an Aniko mitra coma which also can cause pigmentation. You can see that here the anna mae trachoma is forms papillary projections within the nail plate. And you can also have some pure carotenoid pigment and then Melanoma and say two can also cause Melanie Kia. This isn't a korean patient and Bowen's disease which we don't see too frequently in the nail but we do see can also be associated with pigmentation. Yeah, we can see pigmentation in the nail from drugs and this is a case of an HIV patient who is receiving zidovudine and you can see pigmentation and then they don't play related to that. And then occasionally you can see external staining of the nail plate causing pigmentation of the nail as well. And then ethnic pigmentation is very common in certain populations. Mideast and asia. So when we're evaluating Melanie Kia and Children. Some of the things that are more high risk or worrisome or when we have rapid change or growth of a pigmented lesion in the nail apparatus and also the continuous expansion of pigmented streaks sometimes to cover the entire nail plate and then color variation of the pigmented band and the presence Hutchinson sign, which mostly is pseudo Hutchinson sign Children because it's not associated with melanoma and then also a variation in the width of the pigmented band. When we look at adults, we worry more about Older people, 60, 70 and above with abrupt onset of pigmentation in the nail or sudden change in color and then occurrence after trauma without evidence of hemorrhage. The areas of highest risk include the thumb, the toe and the index finger. And then when we get darker and irregular pigmentation, we worry more. In adults we especially worry about Hutchinson signed because in adults, Hutchinson side is most more likely associated with melanoma and not pseudo Hutchinson science. So Durmus coptic examination of melancholia, the nail unit sort of difficult to do DeMoss copy on because the melanin pigment is deposited under the nail plate and it's hard to see a lot of the different subtle changes you see it's useful and I think the separated if hemorrhage is the cause of the pigmentation or melanin pigment is and it's helpful in determining micro Hutchinson sign along the proximal mail folder along the edges of the nail, but it's not visible to the naked eye, but it's difficult to use democracy copy to decide of Nicaea lesion is benign or malignant and a lot of patients fall into a gray area. Durmus coptic features of nail matrix nevis was looked at in adults and Children and a study from Korea that was published in Jad and they had 58 Children with with 56 or 58 nail plate Nevis is In 56 Children and they had 35 adults with 30 or 30 for adults with 35 lesions. When they looked at these lesions became aware of the fact that neo matrix neath and Children can have a lot of worrisome clinical signs. A here we can see that there's pseudo Hutchinson signed with pigmentation in the proximal nail fall there's a triangular sign, a kind of a triangular shape to the pigmentation, and we also have the dots and globules in this example here and B. You can see a black very darkly pigmented band with pseudo Hutchinson sign. And over here we can see dots and global's we can see covering of the entire nail yeah, plate under near nail bed under the nail, covered with pigmentation and we can see some pigmentation extending out beyond that. Then here there's black and brown discoloration with irregular pigmentation. These are examples of some of the nail matrix from adults and here you can see a fairly thin well demarcated line of pigmentation over here, there's a little bit thicker line of pigmentation, but again, well demarcated here, There is a area of pigmentation that does show pseudo Hutchinson signed with some splinter hemorrhage as well. And then here there is a biopsy has been done which caused some dystrophy of the nail plate and a nail that has multiple areas of pigment banding. But again they're more uniform type of banding. So in summary the Durmus coptic findings showed nail matrix nearby and Children have more melanoma associated features than in adults nearby. And Children are darker and multicolored and triangular shape of the pigmentation as well as dots. Global's and pseudo Hutchinson sign. Well, so we'll switch gears for a little bit and we'll talk a little bit about the surgical evaluation of melon, Ekeus triana and this is a patient I had was eight year old girl who had this under Neil and her parents were worried there was a family history of melanoma. So we wanted to do a biopsy. Just confirmed that there was nothing there that we needed to worry about. So in doing these biopsies I like to do a digital block using 2% lidocaine without epinephrine and it gives you a very good anesthesia. And then after you get the block in you can convulse the nail plate when you take the nail plate off frequently. The back of the nail plate will have pigmentation. You can see the pigmented streak coming down the nail plate here and I'll frequently send that in for pathology because occasionally you will see cells in there, although not too frequently. And then reflecting back again, remembering that the pigmentation is usually going to be on the more distal part of the matrix. And here there's a little tiny bit of pigmentation. It's kind of hard to see. We the little we split the proximal nail fold to get a little bit better visualization. And then I did a little wedge removal of the nail plate and part of the nail bed which allows for when your pathologist is looking at it for a very well oriented specimen where you can see things easier to decide what's going on. And here she comes back in about two weeks for suture removal and you can see the beginning to heal and things look pretty good. There's about six or eight weeks and usually the nails a little disrupted after you do this kind of procedure. But then it heals and settles out over time. So I'm looking at the pathology. This is a nice specimen that most dramatic pathologists or pathologist in general would be glad to get. You can see the proximal nail fold matrix area here and you can see the epithelium, there is a little different. And then you can see the nail bed epithelium and there's a little break here but it goes all the way out into the distal nail epithelium there. And when we look at higher power here, we can see that there are some nests of Niva cells here and here. There is some two. We can see that actually the pigmentation doesn't expand extend way back into the proximal nail fold is more on the kind of the distal part of the matrix. It's a very benign looking thing. Here is a another method of biopsy that I haven't done. But I just thought it was interesting to see where they basically reflect, reflect the proximal nail fold to expose the area of pigmentation. And you can see the area of pigmentation is there and then they excise that area and they leave the nail plate intact distantly, which gives some protection to the nail bed as then things grow and the nail plate should move forward and eventually you get ah a healed nail that looks nice like this one over here. So there was an article in the jet again uh in 2018 looking at sub bungle, a typical indigenous Milan acidic proliferations and Children and adolescents. And they did kind of a clinical pathologic study they get in Children a lot of times some of the lesions are clinically quite worrisome. And even under the microscope, under normal histological evaluation, they have worrisome features. And so they were trying to look at these lesions and decide, you know, we're there easy ways to separate them out in terms of being able to decide which lesions were early melanoma melanoma in sight, two in which lesions were typical but not melanoma. These are some of the lesions they looked at 11 lesions and then they did uh histology on them. And here's a case showing the heavy pigmentation and you can see that it's kind of hard to see individual melanocytes because of the heavy pigmentation, but it involves the nail matrix epithelium. When you can see the proximal nail fold here. So they used immuno peroxide a stain and this helps to kind of separate things. But the histology still is worrisome. There's pageant toyed like growth things that are adults would be very worried about the Children are less worried about in these cases they four of the cases they used the fish or fluorescent and cyp two hybridization technique with a set of probes to look at the genetic chromosomally changes within the cells which were abnormal. And with the with a group of probes they use they got a 94% sensitivity and a 96% specificity for melanoma compared with nearby and in one of the four lesions they looked at, they had positive immuno fluorescence hybridization with the 11 Q 13 With greater than 38% of the nuclei of a typical junction melanocytes showing this change supporting the diagnosis of melanoma insight to. So for more difficult cases, this is a technique that I think it will be more useful in time and the genetic profiling and evaluation of these atypical clinically and histological lesions is going to be benefited by our ability to do more genetic mapping. So in summary the pediatric sub bungle, a typical indigenous want to say proliferations are difficult to classify. The lesions can be histological and distinguishable from adult melon on site to and fluorescence in situ hybridization may prove useful to further stratify the risk in difficult cases. Complete excision is recommended in higher risk cases. So I'm gonna look a little bit of nail apparatus melanoma. Now This is a case that was published in the Jad in 2015. And basically they looked at 49 patients with nail apparatus melanoma and they looked at their initial clinical presentation. Yeah. And nail apparatus melanoma accounts for 20 to 30% of all Akram melanomas, Neil apparatus melanoma accounts for like 10 to 20% of all cutaneous melanomas and agent patients. And acro melanoma typically has the worst prognosis than other melanomas. And clinical pathologic characteristics include higher all sort of rate and deeper Breslow thickness typically. And again, the whole apparatus melanoma begins as longitudinal Melanie Kia. About 36, of the time. In this particular study, they had 49 patients in 29 of them presented with longitudinal Melanie Kias. The initial presentation. When melanoma has become more progressed, they can be accompanied by nail dystrophy periodical pigmentation and nail plate ulceration and a nail apparatus melanoma which starts as a longitudinal as long as you know, Monica and arises from the neo matrix can spread to other parts of the nail and then develop as a mass underneath the nail and cause nail flight dystrophy. So it's kind of a progression is the longer the tumor has been there. Here's a patient who presented with linear melon Nicaea. You see that there's a pigment streak there but it's kind of ill defined covers a larger area. So a total of the 10 of the 29 patients presented with a nail bed mass and here's a nail bed mass where the nail plate has been destroyed. There is pigmentation within the nail bed and usually when people present this kind of a setting that they have, they have a more advanced you are that's invaded and is causing more problems. And here's nail plate dystrophy that occurred after the patient had melanoma on their nail. For a while the nail began to grow abnormally and then began to split. And here is significant pigmentation extending beyond the nail that a nail matrix in kind of a Hutchinson sign except a very significant one with pigmentation extending along over a lot of the distal thumb. And here is patient who presented just with a nail bed mass that was ulcerated and also pigmented. Yeah. And then this is always something to keep in mind. These are always cases that haunt you. So we have to remember that patients can also get a melon attic melanoma on the toe, around the digits. And interestingly, a melodramatic melon almost typically arise more distantly on the nail plate than they do in the proximal nail fold. For reasons that aren't totally understood, but they have a much worse prognosis because there usually is a significant delay in diagnosis. So again, kind of summarizing things. Nail apparatus melanoma can begin as wanted to know Melanie Kia and like 38-76% of cases in this particular study was about 66% of the case has had it nail apparatus mama has a different clinical pathologic features such as disease station Breslow thickness, both of which depends on the initial diagnosis, the apparatus melanoma, it begins as Melanie Kia tends to have a better survival than patients who have other presentations. Yeah, so summarizing, I guess points for melon, icky and adults, Older people 60, 70 years old and older or higher risk for having melanoma sudden change in color again as bad prognostic sign Again, occurrence after trauma without evidence of hemorrhage of the people. I can think of what I've seen in my last 32 years. The people who presented with trauma and then something that just didn't heal. It's a fairly common presentation. Unfortunately, the location to the first toe, the thumb or highest or high risk areas as well as the first finger, dark and irregular pigmentation. The president of Hutchinson sign again, nail unit DeMoss copy is limited by the fact that you're evaluating the sites of melanin deposition rather than being able to see the underlying patterns in the a book pigmentation. So the pathology and adults early melanomas can be difficult to diagnose because the pathologic changes could be subtle and that's something important to remember. You mean approximately stains can be helpful to identify melanocytes and atypical monos sites and heavily pigmented lesions and genetic analysis of in adults is also something that's beginning to be used more in adults. Complete surgical removal of a typical lesions is recommended because of the risk of melanoma progression, especially in early lesions and invasive melanoma. It needs to be treated aggressively because we know it exists much more frequently in adults. Uh huh. When we look at Children again concerning history, rapid change and growth of a pigmented lesion on the nail apparatus, continuous expansion of pigmented streak sometimes covering the entire nail plate. In Children, you can really get some pretty worrisome looking clinical features that actually aren't malignant. That's kind of one of the things you should bring home from this lecture. So even when they have color variation and pigmented bands and in the presence of most of the time and Children, the Hutchinson Zion is really a pseudo Hutchinson scientists pigmentation is extending beyond the nail bed and plate into the surrounding skin, but it's not associated with melanoma. And again, Durmus coptic examination of these is difficult. Thank you. But in Children you can find these leases that are basically his theologically indistinguishable from adults of jungle melanoma. And say to so this is where genetic profiling with fish analysis and other types of genetic diagnosis I think is going to be important. Moving into the future and remember that there is a high bar for diagnosing melanoma insight to and basic melanoma and Children as opposed to adults because it is extremely rare as it was talked about earlier by the pediatric discussion. Clinically and pathologically, worrisome lesions should be considered for a complete conservative removal. Fish positive tumors should be treated aggressively as as though they are melanomas and invasive melanoma again and Children and adolescents is extremely rare. So when you make that diagnosis, you want to make sure you covered all possible diagnostic tools. You have to help you make that diagnosis. No, concludes my talk that there's any questions I'd be happy to answer. Thank you fred dr Fish also is board certified in dramatic pathology which helps along with this dermatology and its most surgical training. Well, um, send the questions to you through the chat room, Doctor Fish, but thank you for an excellent presentation that covered all the important points. Well, thank you for inviting me. All right. Stay warm. Yeah, I'll try it
