What are myxoid cysts. How do these benign lumps form near fingernails and toenails. What symptoms do myxoid cysts cause. Which treatment options are available for removing myxoid cysts.

What Are Myxoid Cysts and How Do They Form?

Myxoid cysts are small, benign lumps that develop on fingers or toes, typically near the nail. Also known as digital mucous cysts or mucous pseudocysts, these growths are usually asymptomatic. The exact cause remains uncertain, but myxoid cysts are often associated with osteoarthritis.

Two primary explanations exist for myxoid cyst formation:

1. Degeneration of synovial tissue around finger or toe joints, often linked to osteoarthritis or other degenerative joint conditions. In some cases, small bony growths called osteophytes may be involved.
2. Overproduction of mucin by fibroblast cells in the connective tissue, unrelated to joint degeneration.

In younger individuals under 30, trauma to the finger or toe may contribute to cyst development. Additionally, repetitive finger motions can lead to myxoid cyst formation in a small number of cases.

Identifying Myxoid Cysts: Key Characteristics and Symptoms

Myxoid cysts have several distinguishing features:

• Small, round or oval bumps up to 1 cm (0.39 inches) in size
• Smooth texture
• Firm or fluid-filled consistency
• Generally painless, though nearby joints may experience arthritis pain
• Skin-colored or translucent with a reddish or bluish tinge, often resembling a “pearl”
• Slow-growing nature

These cysts commonly form on the dominant hand, particularly on the middle or index finger near the nail. Toe cysts are less frequent. When a cyst grows over part of the nail, it can cause grooving or splitting of the nail, and in rare cases, nail loss.

Can myxoid cysts grow under the nail?

While uncommon, myxoid cysts can develop beneath the nail. These subungual cysts may cause pain depending on how significantly they alter the nail shape. If a myxoid cyst becomes injured, it may leak a sticky fluid. Any signs of infection warrant immediate medical attention.

Myxoid Cyst Demographics: Who Is Most Affected?

Myxoid cysts predominantly affect individuals between 40 and 70 years old, though they can occur at any age. Women are twice as likely as men to develop these cysts. The prevalence of myxoid cysts among people with osteoarthritis is significant, with estimates ranging from 64% to 93%.

Are younger individuals at risk for myxoid cysts?

While less common in younger age groups, myxoid cysts can still develop in individuals under 30. In these cases, trauma to the finger or toe may play a more significant role in cyst formation compared to older adults, where osteoarthritis is often the primary contributing factor.

Diagnosis and Monitoring of Myxoid Cysts

Most myxoid cysts can be diagnosed through visual examination and patient history. In some cases, additional diagnostic tools may be employed:

• Dermatoscopy: A non-invasive technique using a magnifying device to examine skin lesions in detail
• Ultrasound: To assess the cyst’s size, location, and relationship to surrounding structures
• MRI: In rare cases, to rule out other conditions or plan for surgical intervention

For asymptomatic cysts that do not interfere with daily activities or cause cosmetic concerns, regular monitoring may be sufficient. Patients should be aware that myxoid cysts rarely shrink or resolve on their own, and should report any changes in size, color, or associated symptoms to their healthcare provider.

When should you seek medical attention for a myxoid cyst?

Consult a healthcare professional if you notice:

• Rapid growth or changes in the cyst’s appearance
• Signs of infection, such as redness, warmth, or purulent discharge
• Pain or discomfort associated with the cyst
• Interference with nail growth or daily activities

Non-Surgical Treatment Options for Myxoid Cysts

Several non-surgical approaches are available for treating myxoid cysts, each with varying success rates and potential side effects:

Infrared Coagulation

This procedure uses heat to burn off the cyst base. Studies show a recurrence rate of 14% to 22% with this method.

Cryotherapy

The cyst is drained, then liquid nitrogen is applied to alternately freeze and thaw the area, aiming to block fluid from reaching the cyst. Recurrence rates range from 14% to 44%, and the procedure may cause pain in some cases.

Carbon Dioxide Laser

After draining the cyst, a laser is used to ablate the cyst base. This method has a reported recurrence rate of 33%.

Intralesional Photodynamic Therapy

This innovative treatment involves draining the cyst and injecting a light-sensitive substance before using laser light to destroy the cyst base. A small 2017 study reported a 100% success rate with no recurrence after 18 months, though larger studies are needed to confirm these promising results.

Repeated Needling

Using a sterile needle or knife blade, the cyst is repeatedly punctured and drained. This may need to be performed two to five times, with recurrence rates between 28% and 50%.

Injection Therapy

Various substances, such as steroids or sclerosing agents (e.g., iodine, alcohol, or polidocanol), can be injected into the cyst. However, this method has the highest recurrence rate, ranging from 30% to 70%.

Surgical Interventions for Myxoid Cysts

Surgical treatments for myxoid cysts boast high success rates, ranging from 88% to 100%. Due to this effectiveness, doctors may recommend surgery as a first-line treatment in some cases.

What does myxoid cyst surgery involve?

The surgical procedure typically includes:

1. Excision of the cyst
2. Covering the area with a skin flap
3. Allowing the flap to close as it heals

The size of the skin flap depends on the cyst’s location and extent. In some cases, the surgeon may also address any underlying joint issues or osteophytes contributing to cyst formation.

Are there potential complications from myxoid cyst surgery?

While generally safe, surgical intervention may carry risks such as:

• Infection
• Scarring
• Temporary or permanent nail deformity
• Reduced range of motion in the affected joint
• Rare cases of cyst recurrence

Patients should discuss these potential risks with their surgeon and follow post-operative care instructions carefully to minimize complications.

Choosing the Right Treatment Approach for Myxoid Cysts

Selecting the most appropriate treatment for a myxoid cyst depends on various factors:

• Cyst size and location
• Associated symptoms or complications
• Patient preferences and concerns
• Overall health and medical history
• Potential impact on daily activities or occupation

Healthcare providers will consider these factors when recommending a treatment plan. In some cases, a combination of approaches may be used to achieve the best outcome.

Is treatment always necessary for myxoid cysts?

Not all myxoid cysts require treatment. If the cyst is asymptomatic, not causing nail deformities, and not interfering with daily activities, observation may be appropriate. However, patients should be aware that spontaneous resolution is rare, and the cyst may gradually increase in size over time.

Living with Myxoid Cysts: Management and Prevention

For individuals living with myxoid cysts, several strategies can help manage symptoms and prevent complications:

• Protect the affected area from trauma or excessive pressure
• Maintain good hand and foot hygiene to prevent infection
• Use padding or protective coverings if the cyst interferes with activities
• Monitor the cyst for any changes in size, color, or associated symptoms
• Address underlying joint issues or osteoarthritis with appropriate treatments

Can myxoid cysts be prevented?

While it may not be possible to completely prevent myxoid cysts, especially in individuals with osteoarthritis, some measures may help reduce the risk:

• Maintain joint health through regular exercise and a balanced diet
• Avoid repetitive trauma to the fingers and toes
• Use protective equipment when engaging in activities that may stress the joints
• Manage underlying conditions, such as osteoarthritis, as recommended by healthcare providers

By understanding the nature of myxoid cysts and working closely with healthcare professionals, individuals can effectively manage these benign growths and minimize their impact on daily life. Whether opting for treatment or choosing to monitor the cyst, staying informed and proactive is key to maintaining optimal hand and foot health.

Causes, Symptoms, Pictures, and Treatment

A myxoid cyst is a small, benign lump that occurs on fingers or toes, near a nail. It’s also called a digital mucous cyst or mucous pseudocyst. Myxoid cysts are usually symptom-free.

The cause of myxoid cysts isn’t certain. They’re usually associated with osteoarthritis. An estimated 64 percent to 93 percent of people with osteoarthritis have myxoid cysts.

Most myxoid cysts occur in people between the ages of 40 and 70, but they may be found in all ages. Twice as many women as men are affected.

Myxoid means mucus-resembling. It comes from the Greek words for mucus (myxo) and resemblance (eidos). Cyst comes from the Greek word for bladder or pouch (kystis).

The exact cause of myxoid cysts isn’t known, but there are two basic explanations.

• The cyst forms when the synovial tissue around the finger or toe joint degenerates. This is associated with osteoarthritis and other degenerative joint diseases. Sometimes a small bony growth formed from degenerating joint cartilage (an osteophyte) may be involved.
• The cyst forms when the fibroblast cells in the connective tissue produce too much mucin (an ingredient of mucus). This type of cyst doesn’t involve joint degeneration.

In some cases, especially with people under 30, trauma to the finger or toe may be involved in causing a cyst. A small number of people may develop myxoid cysts from repetitive finger motion.

Myxoid cysts are:

• small round or oval bumps
• up to 1 centimeter (cm) in size (0.39 inch)
• smooth
• firm or fluid-filled
• not usually painful, but the nearby joint may have arthritis pain
• skin-colored, or translucent with a reddish or bluish tinge and often looks like a “pearl”
• slow-growing

Share on PinterestMyxoid cyst on index finger. Image Credit: Wikipedia

Myxoid cysts tend to form on your dominant hand on the middle or index finger, near the nail. Cysts on toes are not common.

When a cyst grows over part of the nail it can cause a groove to develop in the nail or it can split the nail. Sometimes it may cause nail loss.

Myxoid cysts that grow under the nail are rare. These can be painful, depending on how much the cyst changes the nail shape.

When you injure a myxoid cyst, it may leak a sticky fluid. You should see your doctor if a cyst shows signs of infection.

Most myxoid cysts aren’t painful. Unless you’re unhappy with the way your cyst looks or it gets in your way, no treatment is necessary. You may just want to keep an eye on the cyst. But be aware that a myxoid cyst rarely shrinks and resolves on its own.

Many possible treatments are available for myxoid cysts, and their pros and cons are well-researched.

In many cases the cyst grows back after treatment. Recurrence rates for different treatments have been studied. Also, some treatment methods may:

• leave scars
• involve pain or swelling
• decrease joint range of motion

If you’re interested in removing your cyst, discuss with your doctor or specialist which treatment might be best for you. Here are treatment possibilities:

Nonsurgical

• Infrared coagulation.This procedure uses heat to burn off the cyst base. A 2014 review of the literature showed the recurrence rate with this method to be 14 percent to 22 percent.
• Cryotherapy.The cyst is drained and then liquid nitrogen is used to alternately freeze and thaw the cyst. The objective is to block any more fluid from reaching the cyst. The recurrence rate with this procedure is 14 percent to 44 percent. Cryotherapy may be painful in some cases.
• Carbon dioxide laser.The laser is used to burn off (ablate) the cyst base after it’s been drained. There’s a 33 percent recurrence rate with this procedure.
• Intralesional photodynamic therapy.This treatment drains the cyst and injects a substance into the cyst that makes it light-sensitive. Then laser light is used to burn off the cyst base. A small 2017 study (10 people) had a 100 percent success rate with this method. There was no cyst recurrence after 18 months.
• Repeated needling.This procedure uses a sterile needle or knife blade to puncture and drain the myxoid cyst. It may need to be done two to five times. The cyst recurrence rate is 28 percent to 50 percent.
• Injection with a steroid or a chemical that shrinks the fluid (sclerosing agent).A variety of chemicals may be used, such as iodine, alcohol, or polidocanol. This method has the highest recurrence rate: 30 percent to 70 percent.

Surgical

Surgical treatments have a high success rate, ranging from 88 percent to 100 percent. For this reason, your doctor may recommend surgery as a first-line treatment.

Surgery cuts the cyst away and covers the area with a skin flap that closes as it heals. The size of the flap is determined by the size of the cyst. The joint involved is sometimes scraped and osteophytes (bony outgrowths from the joint cartilage) are removed.

Sometimes, the surgeon may inject dye into the joint to find (and seal) the point of fluid leakage. In some cases, the flap may be stitched, and you may be given a splint to wear after surgery.

In surgery and in nonsurgical methods, scarring that cuts the connection between the cyst area and the joint prevents more fluid from leaking to the cyst. Based on his treatment of 53 people with myxoid cysts, one researcher has argued that the scarring can be accomplished without the need for cyst removal and a skin flap.

Home methods

You can try treating your cyst at home by using firm compression every day for a few weeks.

Don’t puncture or try to drain the cyst at home because of infection risk.

There’s anecdotal evidence that soaking, massaging, and applying topical steroids to myxoid cysts may help.

Myxoid cysts aren’t cancerous. They’re not contagious, and they’re usually symptom-free. They’re often associated with osteoarthritis in fingers or toes.

Many treatments are available, both nonsurgical and surgical. Recurrence rates are high. Surgical removal has the most successful outcome, with the least recurrence.

If your cyst is painful or unsightly, discuss potential treatments and outcomes with your doctor. See your doctor right away if your myxoid cyst has signs of infection.

Nail Tumors: Don’t Ignore the Signs

You may not pay much attention to the appearance of your nails.

Even if you regularly treat yourself to mani-pedis, what’s hidden beneath the polish may be threatening your health. Different types of nail disorders and tumors vary in appearance and size.

Some are cancerous, and others are just unsightly and irritating.

People with darker skin are particularly vulnerable to nail tumors’ risks because discolorations on or under the nail may be considered normal and go ignored. “Many of my patients of color are surprised to learn that skin cancer can occur in the nail and may appear as a brown or black streak that runs the length of the nail,” says Brian Morrison, M.D., a dermatologist with Sylvester Comprehensive Cancer Center.

This might sound like an aesthetic concern, but the metastasis of a cancerous tumor can be fatal.

“This is what killed Bob Marley. He had a subungal (beneath the nail plate) melanoma on his toe,” says Dr. Morrison.

“While persons of color are not necessarily more likely to get nail tumors, they are less likely to seek out routine dermatological care for skin cancer screenings, including the evaluation of all 20 nails,” he says.

Signs to look for when examining your nail bed.

Malignant (cancerous) and benign (non-cancerous) growths can look similar in appearance. For an accurate diagnosis and treatment, a dermatological exam and, potentially, a biopsy are needed.

The most serious nail tumor, melanoma, may look like a brown, black, or grey line or streak on or underneath the nail. The nail may split or appear flaky and scaly. The texture of the nail might be thin, uneven, or ridged. Bumps may form under or around the nail.

When multiple nails are involved, the condition is less likely to be cancerous.

Dr. Morrison, along with Sylvester’s team of dermatological oncologists, treat malignant nail tumors, such as:

• melanoma
• squamous cell carcinoma (or Bowen’s disease)
• onychocytic carcinoma

Common benign (non-cancerous) nail tumors include:

• onychopapilloma
• nevus (moles)
• lentigo
• onychomatricoma
• glomus tumor

Are these tumors contagious to others?

No. But squamous cell carcinoma of the nail has been linked with Human Papilloma Virus (HPV), which is infectious and can cause warts. “It is possible that getting the HPV vaccine could help protect against this type of cancerous tumor,” says Dr. Morrison. “More research will need to be done in this area to confirm any true benefit.”

What is the treatment for nail tumors?

“The recommended treatment for malignant nail tumors is surgical excision of the lesion,” Dr. Morrison says. “Non-malignant tumors do not always require surgical removal unless they are painful or otherwise symptomatic.”

“The outcome for patients depends on where the tumor is and how aggressively it’s treated,” he says. “Excision of the complete nail matrix (the cells that make up the hard part of the nail) may result in permanent nail dystrophy (like a split nail). When a tumor involves only the distal matrix (the cells that make up the underside of the nail), a biopsy or surgery is less likely to cause visible damage because it’s hidden beneath the remaining nail plate. ”

Everyone, and especially those with dark skin, should be mindful of changes in the appearance or texture of their nail beds. If you see something suspicious, don’t ignore it or assume it will resolve on its own. See a dermatologist for an exam and an appropriate course of treatment.

Dana Kantrowitz is a contributing writer for UMiami Health News.

Tags: Dr. Brian Morrison, nail tumors

symptoms, causes, stages, diagnosis and treatment of nail melanoma

Contents

• Causes of nail melanoma
• Signs of subungual melanoma
  • Early and late symptoms
  • How to distinguish from a hematoma
  • How to distinguish from a nevus
  • How to distinguish it from a fungus
• How quickly subungual melanoma develops
• Nail bed melanoma classification
• Diagnosis of melanoma of the nail
• Treatment of melanoma of the nail plate
• Forecasts
• Prophylaxis

Subungual melanoma is a type of skin cancer that affects the nail bed. The disease is extremely rare, has a direct relationship with race. In representatives of the Caucasian race, melanoma occurs in 1-3% of cases, in representatives of the Negroid and Mongoloid races – in 40% of cases. The disease is typical for the age group of 63-67 years. Like all forms of melanoma, subungual melanoma is characterized by rapid progression, extremely severe course and high mortality. The deterioration of the prognosis contributes to the lack of diagnosis – the correct diagnosis at an early stage is made only by 3% of patients. Nail melanoma is treated with surgery, radiation therapy, and chemotherapy. Survival is low, largely due to late diagnosis.

Causes and risk factors for the development of subungual melanoma

The main cause of all types of melanoma of the skin is excessive exposure to ultraviolet radiation, which leads to the transformation of melanocytes. Nail bed melanoma is an exception in this regard. The cause of subungual melanoma is chronic injury to the skin of the fingers, palms and feet:

• mechanical trauma;
• cosmetic and medical procedures;
• permanent ingrown nails;
• frostbite and burns;
• exposure to aggressive chemicals.

The following risk factors increase the likelihood of developing nail melanoma:

• numerous nevi on the body;
• light skin, red hair and freckles – for the Caucasian race;
• alcohol and nicotine abuse;
• unfavorable ecological situation;
• hereditary burden according to oncopathology.

Symptoms of nail melanoma

Subungual or acral lentiginous melanoma affects the subungual bed, interdigital spaces, skin of fingers, palms and soles. The first symptom of the disease is the formation of a pigmented strip under the nail or in the area of ​​​​the nail fold. Considering that the main cause of the disease is trauma, most patients do not pay attention to this sign, considering the strip to be an ordinary hematoma. This causes low accessibility to a dermatologist and late diagnosis of the disease.

A tumor on the fingers develops one and a half times more often than on the toes. In 58% of cases, the big toe and hands and feet suffer from subungual melanoma, this is due to more frequent trauma.

As the subungual melanoma progresses, the following symptoms appear:

• ulcers with bleeding in the nail bed and ridge;
• brittle, striated nails;
• neoplasm growth with nail plate rejection;
• pain in the affected nail bed, itching and burning.

The pain syndrome reaches such severity that the patient cannot move his arm or lean on his leg if the cancer has appeared on the toes.

Late stage subungual melanoma is characterized by common symptoms:

• fatigue, weakness, fainting;
• pale earthy skin color;
• sudden weight loss;
• persistent fever.

Symptoms are rather poor and non-specific, disguised as trauma or infection. This contributes to late diagnosis and poor prognosis for life and health. Another factor negatively affecting the diagnosis is the absence of pigmentation at an early stage in 40% of patients.

How to distinguish subungual melanoma from hematoma

In case of hemorrhage under the nail, the hematoma is demarcated by the nail plate, which keeps it in the bed and does not allow to dissolve. Outwardly, such a hematoma is very similar to a cancerous tumor. However, there are signs that make it possible to distinguish subungual melanoma from hematoma:

• there is a clear relationship between trauma and hematoma;
• hemorrhage is always limited to the nail plate, and melanoma grows on the nail fold, cuticle;
• hematoma is mobile, shifts as the nail grows;
• hematomas are blue-red-black, melanomas are brown and black;
• hematoma is surrounded by punctate hemorrhages.

How to distinguish subungual melanoma from nevus

Nevus – a large pigmented spot, has a congenital or acquired character. Of all the pigmentations, the nevus is most similar to melanoma; it is difficult to find the differences between these diseases. The nevus has clear boundaries, while in melanoma they are more vague. It is possible to reliably differentiate diseases only with the help of histological examination. Therefore, all nevi require close attention, observation and regular examination by a dermatologist.

How to distinguish subungual melanoma from fungus

Fungal diseases of the nails are sometimes accompanied by pigmentation and hemorrhages, in such cases they are similar to melanocytic tumors. It is possible to distinguish subungual melanoma from a fungus by the following signs:

• the fungus affects only the nail plate, and melanoma first forms under the nail, and then it grows into it and captures adjacent tissues;
• the nail plate with a fungal infection acquires a yellowish color, thickens, becomes brittle and crumbles;
• fungus spreads to other nails, but melanoma remains on one finger;
• fungus predominantly affects the big toes, while melanoma is more common on the fingers.

How quickly subungual melanoma develops

Subungual melanoma develops and metastasizes extremely quickly – already a year after the first symptoms appear, the disease is incurable, the prognosis is unfavorable. The peculiarity of this type of cancer is unpredictability, high frequency of complications. Metastasis usually occurs in the liver and lungs, and metastatic tumors are sometimes much more dangerous than the primary focus.

Classification

A separate Breslow classification has been developed for subungual melanoma. It takes into account the cellular structure of the tumor and the degree of germination of the nail bed:

• first – atypical cells capture only the basal plate of the epidermis, there are no metastases;
• second – the tumor grows into the papillary layer of the dermis, is available for inspection with the naked eye;
• third – atypical cells affect the entire papillary layer;
• fourth – all layers of the skin are affected by the tumor;
• fifth – the neoplasm grows into the subcutaneous tissue, gives lymphogenous and hematogenous metastases.

The generally accepted TNM classification takes into account the size of the primary focus, the presence of metastases:

• T0 – it is impossible to find the primary focus;
• Tis – melanocytic dysplasia, precancerous condition;
• T1 neoplasm thickness less than 1 mm;
• T2 – neoplasm thickness 1-2 mm;
• T3 – tumor thickness 2-4 mm;
• T4 – tumor thickness more than 4 mm;
• N0 – no damage to regional lymph nodes;
• N1 – one regional node is affected;
• N3 – no more than 3 lymph nodes are affected;
• N4 – defeat of 4 or more lymph nodes;
• M0 – no metastases;
• M1 – there are distant metastases.

ICD-10 disease code – C43.

Diagnosis of nail bed melanoma

Subungual melanoma is diagnosed by a dermatologist and oncologist. After examining the altered nail bed, the doctor collects an anamnesis:

• the presence of risk factors for the disease;
• hereditary predisposition;
• the duration of the onset of symptoms, the dynamics of their development.

Final confirmation of the diagnosis requires instrumental and laboratory examination. At an early stage, laboratory tests are uninformative. As the tumor grows, intoxication of the body, nonspecific changes appear in the analyzes:

• moderate to severe anemia;
• increase in ESR;
• reduced protein levels;
• increase in liver enzymes.

Instrumental and histological methods of diagnostics are the most informative:

• luminescent microscopy allows distinguishing a malignant process from a benign one;
• smear-imprint for histological examination, which specifies the cellular type of the tumor;
• Ultrasound, radiography, CT and MRI are used to detect metastases.

The ABCDEF algorithm is also used to diagnose acral melanoma:

• A — age, African and Asian races;
• B – black and brown neoplasm;
• C – no change in nail color after treatment;
• D – damage to the fingers;
• E – the spread of pathological pigmentation on the nail roller, fingertip;
• F – the presence of melanoma in the immediate family of the patient.

Methods of treatment of subungual melanoma

Melanoma under the nail is practically insensitive to radiation and chemotherapy, the most effective method of treatment is surgery. However, skin cancer is usually diagnosed late, so even surgery does not guarantee recovery. To improve the prognosis, the operation is combined with radiation and chemotherapy.

Before the operation, the patient is prescribed a course of chemotherapy, the purpose of which is to reduce the size of the tumor and partially destroy the atypical cells. The volume of surgical intervention is determined by the size of the tumor. Statistical data indicate that the survival rate after amputation of the finger at the level of the middle phalanx and amputation of the entire finger is the same. Taking into account less trauma for the patient, preservation of the functionality of the hand, it is preferable to perform incomplete amputation.

In order to destroy the remnants of atypical cells and metastases after surgery, patients are prescribed a second course of chemotherapy and radiation. At the experimental level, immunotherapy and targeted therapy are used to treat subungual melanoma.

Prognosis for subungual melanoma

Prognosis for subungual melanoma is unfavorable. Even surgical treatment does not exclude the possibility of recurrence of the disease. Full recovery can only be achieved with initial treatment of subungual melanoma, and this is extremely rare. Cancer recurrence after treatment at other stages occurs in 40-60% of patients. The five-year survival rate already at stage 2 melanoma is only 42% of patients. Patients with advanced melanoma live an average of 6-8 months.

Disease prevention

Prevention includes primary and secondary methods. The primary concerns patients with a family history of melanoma. They require genetic testing to determine the risk of developing cancer, identification and elimination of risk factors. Secondary prevention involves careful monitoring of moles and nevi, timely examination by a dermatologist when symptoms suspicious of cancer appear.

Sources:

1. Myasnyankin M.Yu. Subungual melanoma. Features of the clinic, diagnosis and treatment / M.Yu. Myasnyankin [et al.] // Problems of oncology. – 2016. – No. 3. – S. 474-478.
2. Yargunin S.A. Surgical treatment options for subungual skin melanoma / S.A. Yargunin [et al.] // Medline.ru. Russian biomedical journal. – 2022. – No. 2. – S. 624-632.
3. Selyuzhitsky I.V. Errors in the diagnosis and treatment of subungual melanoma / I.V. Selyuzhitsky [et al.] // Russian journal of oncology. – 2004. – No. 4. – S. 33-35.
4. Myasnyankin M.Yu. Subungual melanoma in the practice of a surgeon and an oncologist / M.Yu. Myasnyankin [et al.] // Stationary-replacing technologies: Ambulatory surgery. – 2017. – No. 1-2. – S. 59-64.
5. Bondarchuk V.M. Subungual melanoma / V.M. Bondarchuk [et al.] // Youth Scientific Forum. collection of articles based on the materials of the CXL student international scientific and practical conference. – 2021.- S. 11-17.
6. Paskhin V.A. Subungual melanoma as a variant of a rare clinical form / V.A. Paskhina [et al.] // Topical issues of modern medical science and health care. Materials of the II International (72nd All-Russian) Scientific and Practical Conference of Young Scientists and Students, II All-Russian Forum of Medical and Pharmaceutical Universities “For Quality Education”. – 2017. – S. 300-303.
7. Matsko D.E. Morphological and immunohistochemical characteristics of subungual melanomas / D.E. Matsko [et al.] // Clinical and experimental morphology. – 2018. – No. 1. – S. 12-18.
8. Kazmina I.B. Differential diagnosis of pigmentary disorders of the nail / I.B. Kazmina [et al.] // Bulletin of a young scientist. – 2019. – No. 1. – S. 11-13.

5.00 out of 5. Votes: 1

Thank you for your rating.

The information in this article is provided for reference purposes and does not replace the advice of a qualified professional. Do not self-medicate! At the first sign of the disease, you should consult a doctor.

Subungual melanoma, nail plate cancer: cure, symptoms, early stages of nail cancer

Subungual melanoma, or nail melanoma as some patients call it, is one of the rarest forms of malignant neoplasms. It develops in the area of ​​the nail bed, at first it looks like a dark or black spot or strip, the size of which gradually increases, affecting the nail fold, the phalanx bone and its soft tissues. The tumor is prone to an aggressive course, the results of treatment to date leave much to be desired. Above is a characteristic subungual melanoma in the photo – this is what this malignant tumor looks like.

Sometimes patients also use the term “nail cancer”, but this is an incorrect name for the disease. Cancer is called malignant tumors that develop from cells of epithelial tissues: skin, mucous membranes. Melanoma is a malignant tumor that originates from melanocyte pigment cells. Thus, in this case, “nail cancer” and “cancer under the nail” are incorrect terms.

By the way, “melanoma on the nail” is also wrong to say that. The tumor is not on the nail, but under it, it’s just visible through it.

Causes of subungual melanoma

Now that we have talked about what nail melanoma is and how to call it correctly, let’s see why it occurs.

Unlike all other malignant skin tumors, in subungual melanoma, excessive insolation practically does not play any role as a provoking factor in the development of the disease. This is confirmed by the fact that the neoplasm often affects the toes, which are almost constantly covered by shoes. In addition, epidemiological data suggest that subungual melanoma is 40% more common in blacks and Mongoloids.

Possible risk factors for the development of melanoma in this localization include:

• Mechanical trauma to the nail. About a third of patients with an established diagnosis noted the presence of mechanical damage to the nail phalanx in history. Most often, the toes, as well as the thumb and forefinger of the working hand, suffer from this. In addition, cosmetic and surgical interventions that are performed for various nail diseases can provoke melanoma.
• Physical injuries – frostbite and burns, use of a laser to treat or remove damaged nails.
• Exposure to chemical carcinogens on nails. About 10% of patients had prolonged contact with chemicals (occupational hazard).
• Hereditary factor. About 5-14% of melanoma patients have genetic defects, in particular, mutations in the CDKN2A, CDK4, MITF, VC1R genes.
• A large number of dysplastic nevi. In the vast majority of cases, the development of subungual melanoma occurs de novo, i.e., on unchanged tissues, but the risks of its development are higher in individuals with a large number of pigmented dysplastic nevi.
• Age over 60 years.

Predisposing risk factors for melanoma in Caucasians include fair skin, red hair, and freckles.

Symptoms of subungual melanoma

Two stages of development are characteristic of subungual melanoma: horizontal and vertical.

In the horizontal stage, pigmented subungual melanoma appears as a brown or black streak under the nail. Its color may be uneven. In a third of patients, there is an expansion of pigmentation with involvement in the process of the free edge of the nail, nail fold and skin.

For pigmentless melanoma (which, by the way, occurs in 30% of cases), such signs are not typical, and the disease goes unnoticed for a long time. The first symptoms develop at the vertical stage, when the tumor begins to invasively grow into the surrounding tissues. At this time, the deformation of the nail occurs. The nail plate becomes dull, loses its natural shine. Its thickness becomes thinner, the nail becomes brittle, exfoliates and breaks easily. As the tumor increases in size, the nail cracks and a bumpy surface is revealed underneath. In the case of pigmentary melanoma, it will be brown or black with patches of more pigmented areas. With mechanical contact, this surface bleeds easily.

Does subungual melanoma hurt? In the early stages, the disease is not accompanied by any discomfort. In some cases, subungual melanoma is accompanied by a burning sensation, itching, or fullness. As the pathology progresses, the tumor involves new tissues in the process, spreading to the soft tissues of the fingers, feet or hands. The pain syndrome increases and the person cannot fully use the affected limb.

Systemic symptoms of melanoma include general weakness, weight loss, persistent fever. When metastasizing, symptoms from the affected organs join. The rate of progression of the disease is different for each patient. In some cases, several years pass, and in others, metastases are detected as early as a year after the primary occurrence of melanoma.

Subungual melanoma: when to worry? You need to see a doctor for any suspicious changes in the nail. Even if it turns out that they are not caused by a malignant tumor, but by another disease, in any case, it is better to start treatment in a timely manner.

In addition to melanoma, there is such a condition as cancer of the nail plate, in the medical language – onychomatricoma. She herself is hidden under the skin, but leads to changes in the nail.

Classification

• 0 stage, or melanoma in situ – the initial stage of melanoma of the nail. There is dysplasia or non-invasive malignant cell involvement.
• stage 1 – the thickness of melanoma is not more than 1 mm, or up to 2 mm, but without ulceration of the surface.
• Stage 2 melanoma is set if the thickness of the ulcerated tumor is more than 2 mm or more than 4 mm in the absence of ulceration of its surface.
• Stage 3 – any thickness of melanoma in the presence of metastases in regional lymph nodes.
• stage 4 – there are metastases in the internal organs.

Among the clinical and morphological types of tumors in the area of ​​the nail bed, as well as on the fingers, in the interdigital spaces, on the palms and soles, acral nail melanoma is often found. It is characterized by some specific features.

Diagnostic methods

Subungual melanoma refers to tumors of external localization, however, timely diagnosis can be difficult due to the similarity of the clinical picture with nevi, subungual hematomas and hemangiomas. To differentiate the nature of the neoplasm, special dermatological research methods are used:

• Dermatoscopy is a visual assessment of pathologically altered tissues using multiple magnification.
• Epiluminescent microscopy — dermoscopic examination of pathologically altered tissues in an immersion medium. This technique allows with a high degree of probability to differentiate a benign neoplasm from a malignant one.

If there are changes in the nail plate, a cytological examination of impression smears can be performed. The final diagnosis is made after the histological conclusion. In the case of melanoma, it is strongly not recommended to take a biopsy so as not to provoke metastasis. Therefore, the study is carried out after a radical surgical operation.

If subungual melanoma cannot be ruled out within two months after the patient’s visit, a marginal resection of the nail plate with matrixectomy is performed, followed by a histological examination of the obtained material. When the diagnosis is confirmed, radical surgery is indicated.

Radiation methods (ultrasound, CT or MRI) are used to determine the stage of the disease, which allow determining the presence of local and distant metastases.

Differential diagnosis

With subungual melanoma, it is often necessary to carry out differential diagnosis with such pathologies as:

• panaritium – purulent inflammation of the tissues of the finger;
• warts – benign neoplasms caused by human papillomaviruses;
• onychomycosis – fungal infection of the nails;
• nevus – a benign neoplasm of pigment cells;
• subepidermal hematoma;
• subungual hematoma;
• Hemangioma is a benign neoplasm of dilated blood vessels.

Treatment of subungual melanoma

The main point in the treatment of subungual melanoma is radical surgery. Its scope is still a matter of controversy. Previously, it was believed that the higher the resection, the lower the likelihood of recurrence and metastases. Therefore, disarticulation of the entire finger was performed. However, studies have shown no statistically significant difference in survival in patients with subungual melanomas who underwent disarticulation compared with those who underwent resection at the level of the middle phalanx of the finger. Therefore, the last option of intervention is currently accepted. This does not worsen the patient’s prognosis and preserves the quality of his life as much as possible.

Radiation therapy

Radiation therapy in the treatment of subungual melanoma is used to irradiate tumor recurrence in the area of ​​the postoperative scar. The second application is the impact on the area of ​​primary lymph nodes to prevent the spread of lymphogenous metastases.

Chemotherapy

Chemotherapy for subungual melanoma can be used in two ways – systemic and regional. At the same time, different protocols may imply adjuvant and neoadjuvant regimens.

Neoadjuvant chemotherapy involves treatment before surgery. This allows you to reduce the size of the tumor and create conditions for its surgical removal.

Adjuvant regimens are prescribed in the postoperative period, and their goal is to destroy the remaining malignant cells, reduce the risk of recurrence and metastasis. As part of chemotherapy, regimens containing dacarbazine, lomustine, tamoxifen, etc. are used. Unfortunately, the effect can be achieved only in 15-20% of patients.

Other therapies

Great promise in the treatment of subungual melanoma lies with immunotherapy and gene therapy. For example, it has been shown that the administration of interferon, interleukin-2, or granulocyte-macrophage colony-stimulating growth factor has a positive effect on the prognosis of treatment – overall survival increases, the relapse-free period is extended.

Suppression of p53 and p16INK4a is proposed as a gene therapy for melanomas. These genes activate pathological signaling pathways, through which the cell acquires the ability to divide uncontrollably and invasively grow into underlying tissues.

Complications

Subungual melanoma is characterized by an aggressive course. This is one of the most aggressive forms of this disease. Radical surgery for an invasive tumor does not guarantee a complete cure and prevention of recurrence or the development of metastases. Most often, metastases are found in the lungs and liver, and in terms of the degree of malignancy they surpass the primary tumor. As the process develops, general complications characteristic of malignant neoplasms join: weakness, anemia, cachexia, etc.

It should be taken into account that surgical removal of the primary focus of melanoma leads to partial loss of function of the affected limb. During surgery, a visible defect is formed on the arm, which is almost impossible to hide from others, plus the functionality of the hand is impaired.

In some cases, surgery on the foot requires resection of the metatarsus. This greatly reduces the support of the operated leg and creates an additional load on other parts of the musculoskeletal system, leading to the development of arthrosis, myositis, muscle spasms and other disorders.

Prevention of subungual melanoma

Prevention of development of subungual melanoma involves the following activities:

• Protection of limbs from mechanical and physical injuries.
• Protection against chemical agents.
• Genetic testing of individuals at high risk of familial melanoma.
• Observation and timely removal of nevi.

Prognosis for subungual melanoma

The prognosis for subungual melanoma depends on many factors, the key factors being Breslow tumor thickness, level of invasion and presence of distant metastases. The 5-year life expectancy in the absence of metastases is about 60%, the median survival is 50-55 months.