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After positive margins at re-excision, a third wider excision achieved negative margins and highlighted multifocal microscopic spread 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was the initial hand lesion difficult to diagnose?","Question",{"text":63,"@type":64},"It appeared subtle and was initially managed as actinic keratosis or inflamed seborrheic keratosis, then failed to resolve, delaying definitive biopsy and diagnosis.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What did the first excision show regarding tumor thickness and margins?",{"text":68,"@type":64},"Histology confirmed malignant ALM with Breslow depth 2.2 mm and no overlying ulceration, with peripheral margins positive for ALM in situ despite negative deep margins.",{"name":70,"@type":61,"acceptedAnswer":71},"How were surgical margins managed after persistent positive margins?",{"text":72,"@type":64},"A second wide local excision and sentinel lymph node biopsy were performed, but margins remained positive for both in situ and invasive ALM, leading to a third, more extensive wide excision with final negative 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Management Strategies  \nMavericAbella, MD Stuart Kuschner, MD Andrea Krajisnik, MD FarinAmersi, MD David Kulber, MD  \nSummary: Acrallentiginous melanoma (ALM) is a rare but aggressive subtype of melanoma that can be easily missed. It may also be underresected during the first surgical excision, mandating additional surgery. An 81-year-old man presented with a pigmented lesion on the dorsum of the hand. Initial dermatologic treatment with cryotherapy failed, prompting an excisional biopsy, which revealed malignant ALM with a Breslow depth of 2.2 mm, with positive peripheral margins forALMin situ. The patient underwent a second wide local excision and axillary sentinel lymph node biopsy. The nodes were negative for tumor. However, invasive ALM was found at the margins of the resected specimen. This necessitated a third wide local excision, incorporating the previous graft and surrounding tissues. Final pathology after the third resection confirmed negative margins. This case highlighted the locally aggressive nature of ALM, its potential for multifocal subclinical spread, and the need for thorough pathological and surgical strategies. The concept of multifocal invasion and field effect warrants attention in surgical planning. (Plast Reconstr Surg Glob Open 2026;14:e7365; doi: 10.1097/GOX.0000000000007365; Published online 6January 2026.)  \nM  \nelanoma involving the hand is a rare clinical entity that poses unique diagnostic and surgical challenges. Despite its clinical importance, there  \nare no published consensus guidelines tailored to hand melanoma, and it is not recognized as a distinct category in tumor registries, limiting the generalizability of large studies.1  \nAcral lentiginous melanoma (ALM), which typically affects the palms, soles, and subungual regions, is the most common subtype in individuals with darker skin types but can also present in lighter-skinned patients. ALM is particularly aggressive and often diagnosed at later stages due to its subtle presentation and slow horizontal growth phase.2 There is increasing interest in the tumor biology of ALM, particularly its tendency for local recurrence and multifocal microscopic spread.2  \nCASE PRESENTATION  \nAn 81-year-old non-Hispanic White man presented for evaluation of a skin lesion on the dorsum of the left hand (Fig. 1) . The lesion had been present for several months, was asymptomatic, and had not changed significantly in  \nFrom the Cedars-Sinai Medical Center, Los Angeles, CA.  \nReceived for publication July 11, 2025; accepted October 28, 2025. Copyright © 2026 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.  \nDOI: 10. 1097/GOX.0000000000007365  \nappearance. The patient had no personal or family history of skin cancer and no history of smoking or drug use. Physical examination revealed a 4-mm, dark, mobile, intradermal/subdermal lesion on the mid-dorsal aspect of the left hand. There was no color variation or border irregularity. Due to the uncertain nature of the lesion, dermatology was consulted.  \nThe dermatologist diagnosed actinic keratosis or inflamed seborrheic keratosis and treated the lesion with liquid nitrogen. However, the lesion did not resolve, prompting a return to the hand surgery clinic. When seen again approximately 2.5 months after initial evaluation, the lesion appeared unchanged. Given the failure to resolve, excision was performed under local anesthesia via a longitudinal elliptical 2.6 × 1.9 × 0.2cm deep incision with 0.1-cm resection margins. The lesion was ","cbCaif5ZbBGZljv0","https://ap.wps.com/l/cbCaif5ZbBGZljv0","pdf",1391448,"English","# Case presentation\n## Initial presentation and diagnostic workup\n## First excision pathology\n## Second wide local excision and sentinel node results\n## Third wide local excision and final pathology","[{\"question\":\"Why was the initial hand lesion difficult to diagnose?\",\"answer\":\"It appeared subtle and was initially managed as actinic keratosis or inflamed seborrheic keratosis, then failed to resolve, delaying definitive biopsy and diagnosis.\"},{\"question\":\"What did the first excision show regarding tumor thickness and margins?\",\"answer\":\"Histology confirmed malignant ALM with Breslow depth 2.2 mm and no overlying ulceration, with peripheral margins positive for ALM in situ despite negative deep margins.\"},{\"question\":\"How were surgical margins managed after persistent positive margins?\",\"answer\":\"A second wide local excision and sentinel lymph node biopsy were performed, but margins remained positive for both in situ and invasive ALM, leading to a third, more extensive wide excision with final negative margins.\"}]","Acral Lentiginous Melanoma of the Hand - Diagnostic Pitfalls and Margin Management Strategies | PDF",1790701812,13]