Management of melanoma of the foot in our subregion: Is preliminary biopsy always required?

Obinna R Okwesili; Emmanuel C Nnadi; Johnson U Achebe

doi:10.4103/ijmh.IJMH_51_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 28 | Issue : 1 | Page : 54-58

Management of melanoma of the foot in our subregion: Is preliminary biopsy always required?

Obinna R Okwesili, Emmanuel C Nnadi, Johnson U Achebe
Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria

Date of Submission	20-Jun-2022
Date of Decision	08-Aug-2022
Date of Acceptance	25-Sep-2022
Date of Web Publication	13-Dec-2022

Correspondence Address:
Obinna R Okwesili
Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_51_22

Abstract

Background: Majority of patients with melanoma of the foot in our subregion present late. After preliminary excision biopsy for these patients, many of them do not come back for further excision when there is an indication to do so following biopsy result. A better result could be achieved by using wider margins for excision biopsy in patients with low socio-economic status. Objectives: We assessed the role of excision of melanoma of the foot without preliminary biopsy as an option in the management of melanoma of the foot in our subregion. Materials and Methods: This was a 5-year retrospective review of patients with melanoma of the foot that presented to a tertiary health institution in Nigeria from December 1, 2014 to November 30, 2019. Results: Half of the patients with lesions that have not advanced locally (35.3%) had wide local excision with 2–3 cm margin without preliminary biopsy, relying on clinical diagnosis of melanoma. Another 35.3% of same number as those mentioned above were managed by doing a preliminary biopsy. Incision biopsy was employed for those with distant metastasis or lesions where amputation of any form was indicated (29.4%). Conclusion: Melanoma of the foot can be diagnosed clinically with a high degree of accuracy in majority of patients. Preliminary biopsy is essential for lesions requiring amputation or very large lesions. For small lesions, excision biopsy with wider margins than is used for preliminary biopsy is beneficial especially for poor patients who tend to delay having a second surgery that is definitive due to financial constraint, ignorance, or other reasons.

Keywords: Foot melanoma, melanoma management, preliminary biopsy of melanoma

How to cite this article:
Okwesili OR, Nnadi EC, Achebe JU. Management of melanoma of the foot in our subregion: Is preliminary biopsy always required?. Int J Med Health Dev 2023;28:54-8

How to cite this URL:
Okwesili OR, Nnadi EC, Achebe JU. Management of melanoma of the foot in our subregion: Is preliminary biopsy always required?. Int J Med Health Dev [serial online] 2023 [cited 2023 May 28];28:54-8. Available from: https://www.ijmhdev.com/text.asp?2023/28/1/54/363253

Introduction

Melanoma has the highest mortality rate among cutaneous malignancies, although it is not the commonest.^{[1],[2],[3],[4],[5]} It has been reported to cause about 75% of all deaths from skin malignancy.^[2] The incidence of melanoma has been reported to be rising worldwide.^[5],[6],[7] Although the incidence is also rising in sub-Saharan Africa, the disease is not as common here as is seen among Caucasians,^[8] and the pattern of presentation also differs. The sole of the foot is the commonest site of occurrence among these sub-Saharan Africans like Nigeria.^{[2],[8],[9],[10]} The most effective mode of treatment of primary melanoma is surgery, especially where complete excision is possible. Preliminary biopsy is used in staging cutaneous melanomas and in determining the minimal resection margins required during the definitive surgery, and the most reliable type of preliminary biopsy based on diagnostic accuracy is an excisional biopsy.^{[4],[11],[12]} This is a type of open biopsy in which the whole tumor is excised with a narrow peripheral margin of 1–3 mm^[4],[12] and deep enough to include a part of the subcutaneous fat deep to the tumor.^[4] Other types of biopsies such as the incisional, punch, and shave biopsies (partial biopsies) which may be indicated in some situations involve the removal of a part of the tumor during a preliminary biopsy. Incomplete excision of melanoma, either as a result of these types of preliminary biopsies or inadvertently resulting from a wide local excision (WLE), most times results in upstaging of the tumor.^[11] Other disadvantages of partial biopsies have been noted to include misdiagnosis, diagnostic uncertainty, and staging inaccuracy.^[11] The thickness of the tumor following histopathology of the preliminary biopsy indicates the margin to be employed during the WLE that follows, and the definitive margin could vary from 10 to 30 mm.^[3] Hieken et al.^[10] reported that about 40–80% of melanomas could be diagnosed clinically prior to preliminary biopsy based on their appearance alone.

In our subregion, majority of the patients with melanoma or other cutaneous malignant lesions present late, and this is most times due to poverty, ignorance, or misinformation. Early diagnosis has been underscored as the major factor in improving the survival of melanoma patients as 80–90% of patients who present early with primary melanoma can be cured with excisional biopsy alone.^[5],[7] Whenever complete excision is possible, the most effective mode of treatment of melanoma is surgery^[6],[13] where an adequate margin of resection is used. Resection margin of 1–2 cm has been recommended for melanomas of the trunk and extremities, including the foot.^[14] For patients with melanoma in situ, a minimum of 0.5 cm margin of excision is recommended and for those with stage I melanoma (thickness ≤ 2 mm) an excision margin of at least 1 cm is recommended, and a minimum of 2 cm margin recommended for stage II melanoma (>2 mm thick or 1.01–2 mm if ulcerated).^[15] These recommendations are the same for the American, UK, and Australian guidelines.^[16] Revised UK guidelines for the management of melanoma^[13] recommended 2–3 cm margin for Breslow’s thickness of 2.01–4 mm and recommended 3 cm margin for thickness greater than 4 mm; it also did not find any advantage in margins greater than 3 cm. When we do preliminary biopsies for patients in our subregion, a good number of them significantly delay the time of having a definitive excisional surgery, whereas others do not come back until they have disturbing symptoms (usually due to metastasis). In these situations, an opportunity to achieve cure via surgical excision only is usually lost. When such scenarios are envisaged, reasonable margins that should ensure cure should be given serious consideration based on clinical assessment and diagnosis of melanoma. The excisional biopsy in this case is then both diagnostic and therapeutic as the excised tissue is still sent for histopathological studies, but there is usually no need to go for further excisions.

This study assessed the role of excision of melanoma of the foot without preliminary biopsy as an option in the management of small melanoma lesions in a poor resource setting.

Materials and Methods

This is a 5-year retrospective review of patients with melanoma of the foot that presented to the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria from December 1, 2014 to November 30, 2019. The Ethical clearance and permission to conduct this study were obtained from the ethics committee of the University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu (UNTH/CSA/329/OL.5: NHREC/05/01/2008B-FWA00002458-1RB00002323). A written informed consent and permission were obtained from each of the patients whose pictures were used for the study. All the guidelines outlined in the Declaration of Helsinki were met. A total of 17 patients with melanoma of the foot were seen during the period under review. Information obtained from the medical records for each patient were the sex, site of the lesion, if preliminary biopsy was done and then the type of biopsy that was done (excisional or incisional), histological diagnosis, tumor clearance at the resection margins, and whether there was further excision following preliminary biopsy. We also checked whether patients had WLE during the initial biopsy, length of follow-up, and evidence of recurrence. We excluded patients who have cutaneous melanoma affecting other parts of the body. We also excluded patients who declined surgery or were lost to follow-up before surgery. Data analysis was descriptive using the Statistical Package for Social Sciences (SPSS, Chicago, IL, USA) version 26 for Windows. Data were presented by percentages and proportions.

Results

Majority of the patients were males (62%), whereas 38% were females. Six of the patients (35.3%) had lesions on the foot without involvement of digits or clinical evidence of metastasis, such as satellite, in-transit nodules, or palpable regional lymph nodes, as shown in [Figure 1]. These patients had excision biopsy, and the resultant defect was covered by split skin graft [Figure 2].

Figure 1: Melanomas on the sole of foot

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Figure 2: Excision of melanoma with split skin grafting of the defect

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Six other patients (35.3%) similar to the group above, with no evidence of metastasis, had preliminary biopsy. These were the patients we managed earlier before we stopped doing preliminary biopsy for such patients. Four of these patients, which constituted 66% of this second group, did not come for definitive surgery, which was indicated based on the results of their preliminary biopsies. They were initially lost to follow-up but two of them came back later with recurrence. One of those that defaulted was not convinced and there was a need for another surgery after the preliminary biopsy. The other patient had no funds for another surgery as she borrowed money to finance the first surgery. Only one-third of those who had preliminary biopsy were available for further review with their histology reports. Both of them had further excisions to obtain clear margins. All the patients who had a WLE without a preliminary biopsy, and one-third of those who had a preliminary biopsy, which were the ones that came back for further excision of their margins, were followed up for at least 1 year. None of these had recurrence.

The rest of the patients either had clinical evidence of metastases or involved a toe (requiring amputation), examples of which are shown in [Figure 3]. Preliminary biopsy in the form of incision biopsy was done for five patients (29.4%), in whom WLE would not ensure local control of the tumor making at least a below knee amputation necessary. These included patients who needed a ray amputation to achieve regional control of the tumor. One of such patients required a repeat biopsy before diagnosis of melanoma was established giving credence to the misdiagnosis that could occur in the use of incisional biopsy. We also used incision biopsy for advanced cases with metastasis to the regional lymph nodes or distant metastasis.

Figure 3: Melanomas involving the toes and melanoma showing in-transit and satellite nodules

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Discussion

Preliminary incisional biopsy is necessary for lesions involving the toes, which would ultimately require amputation. We also did preliminary biopsies for lesions that were quite large or had obvious evidence of local or distant metastasis. Some patients presented early with small lesions that did not involve the digits and had no in-transit nodules or involved the regional lymph nodes. For these patients, we preferred to do WLE with 2 cm margin without preliminary biopsy that required only about 1–3 mm margin. We started this after our initial experience of doing preliminary biopsy in which some of our patients were not convinced of the need for further surgery or did not have enough funds for another surgery. Some of these patients had tumor recurrence. A margin of 2–3 cm has also been recommended by the National Guidelines for Management of Cutaneous Melanoma.^[13],[14] Diagnosis of melanoma for these patients was made clinically. The features that made clinical diagnosis reliable were that majority of melanoma were dark, had irregular borders, and had diameter that was usually more than 5 mm.^[17] However, in each of these instances, our diagnosis was confirmed by histopathology findings. We also did not have to take patient back for further excision of the margins.

We observed that after preliminary biopsy for some patients, they presumed that they have had adequate treatment and did not turn up for further surgeries even when their Breslow’s thickness indicated that they needed so for a wider margin. These patients were adequately counseled on the prognosis of the melanoma. Others delayed in presenting themselves for surgery due to limited finances. We also had patients who were not interested in the histopathology report and the possible need for other modalities of treatment such as chemotherapy. Majority of the defects were usually not suitable for direct closure. We covered most of the defects using skin grafting which in most cases were done on a later date, after reviewing the histology report for clear margins. Fasciocutaneous flaps are also suitable options for closure of these defects.^[18] There were patients who presented with recurrent tumors following prior excision in a private hospital not run by specialists. A number of these did not have the tumors excised in the first surgery sent for histopathology, whereas others did not go back to the hospital to collect the histopathology report and did not wait for a referral from the peripheral hospital.

Ray amputation was also done for patients with lesions involving the toes. Some patients had below the knee amputations done by the orthopedic surgeons. A number of patients required multidisciplinary management. There are patients who defaulted after less than 1 year of follow-up.

Conclusion

Melanoma of the foot can be diagnosed clinically in a good number of cases. Preliminary incisional biopsy is essential for lesions involving the toes which would ultimately require amputation. It is also necessary to carry out a preliminary biopsy for lesions that are quite large or have obvious evidence of local or distant metastasis. For small melanoma lesions, we carried out a WLE which also served as primary treatment, and a specimen was used to confirm diagnosis in each of these cases. This was done for selected patients, most of which were indigent and had a poor attitude to their health. This was beneficial to these poor patients who tend to delay having a second definitive surgery due to financial constraints, ignorance, misinformation, and other reasons. This is useful in the absence of facility for frozen section. Majority of patients in our subregion presented late and were not suitable for this form of management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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