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A 52-year-old Syrian man presented with an ulcerative lesion on the left hallux; histopathology after excisional biopsy and amputation showed malignant melanoma with subcutaneous invasion, Clark level V. One metastatic inguinal lymph node (pN1) was identified, but progression occurred within 4 months, with PET-CT demonstrating hepatic and pulmonary metastases (stage IV). BRAF testing was negative, immunotherapy was unavailable, and carboplatin plus paclitaxel chemotherapy was used, underscoring diagnostic and therapeutic challenges in resource-limited settings.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/metastatic-subungual-melanoma-of-the-hallux-a-case-report/460439/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/metastatic-subungual-melanoma-of-the-hallux-a-case-report/460439.png","ImageObject",300,407,{"name":92,"@type":93},"dabgoudw","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",11,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"Why is subungual melanoma often hard to diagnose early?","Question",{"text":113,"@type":114},"Subungual melanoma is frequently misidentified in early stages as warts, fungal infections, hematomas, or diabetic foot lesions, leading to delayed recognition and worse outcomes.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What did the case reveal after biopsy and amputation?",{"text":118,"@type":114},"Histopathology confirmed ulcerated malignant melanoma at Clark level V with subcutaneous invasion but no bone involvement, and regional lymph node dissection found one metastatic inguinal node (pN1).",{"name":120,"@type":111,"acceptedAnswer":121},"How was the patient treated after disease progression?",{"text":122,"@type":114},"The disease progressed to stage IV within 4 months; PET-CT showed hepatic and pulmonary metastases. 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Karger AG, Basel [www.karger.com/cro](www.karger.com/cro) |\n\nThis article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC) ([https://karger.com/Services/OpenAccessLicense](https://karger.com/Services/OpenAccessLicense)). Usage and distribution for commercial purposes requires written permission.  \nCase Report  \nMetastatic Subungual Melanoma of the Hallux: A Case Report  \nMohammad AlaaAldakak Rahaf Massoud Hussein Aljbawi Aya Alkhdr Batoul Aljawabra Ahmad Al-Bitar  \nFaculty of Medicine, Damascus University, Damascus, Syrian Arab Republic  \nKeywords  \nSubungual melanoma · Acral lentiginous melanoma · Metastatic melanoma · Wild-type BRAF · Case report  \nAbstract  \nIntroduction: Subungual melanoma is a rare and aggressive variant of acral lentiginous melanoma (ALM), often misdiagnosed in its early stages. It typically affects older individuals and has a poor prognosis due to delayed recognition. Management is further complicated in low-resource or conflict-affected settings. Case Presentation: We report the case of a 52-year-old Syrian male with no significant medical history who presented with an ulcerative lesion on his left hallux. Histopathological evaluation following excisional biopsy and hallux amputation revealed ulcerated malignant melanoma, Clark level V, with subcutaneous invasion but no bone involvement. Regional lymph node dissection identified one metastatic inguinal node (pN1). Despite initial surgical management, the disease progressed within 4 months, with PET-CT revealing hepatic and pulmonary metastases (stage IV). The patient tested negative for BRAF mutations and, due to unavailability of immunotherapy, was treated with systemic chemotherapy (carboplatin and paclitaxel). This case highlights the diagnostic and therapeutic challenges in managing advanced subungual melanoma, particularly in settings with limited access to molecular testing and modern therapies. The lesion’s aggressive course and rapid progression despite surgery reflect the poor prognosis associated with late-stage ALM and the necessity of early recognition. Comparisons with similar cases from the literature reveal both unique and shared features in tumor behavior, diagnosis, and treatment strategy. Conclusion: Subungual melanoma can progress rapidly and metastasize even after seemingly adequate local treatment. Early detection, prompt excision, and access to targeted and immune-based therapies are crucial to improving outcomes. In resource-limited environments, comprehensive care is further hindered, underscoring the importance of global efforts to improve cancer care equity.  \n© 2025 The Author(s) .  \nPublished by S. KargerAG, Basel  \nCorrespondence to:  \nMohammad Alaa Aldakak, alaa.dkak41  [gmail.com](gmail.com)  \nCase Reports in Oncology  \nCase Rep Oncol 2026;19:67–73 68  \n\n| DOI: 10. 1159/000549911 | © 2025 The Author(s) . Published by S. Karger AG, Basel [www.karger.com/cro](www.karger.com/cro) |\n| --- | --- |\n\nAldakak et al.: Metastatic Subungual Melanoma of the Hallux  \nIntroduction  \nAlthough melanoma is a rare form of skin cancer, it accounts for approximately 75% of skin cancer-related deaths [1] . Historically, its first documentation is attributed to Hippocrates in the fifth century [2]. Among its four main subtypes, acral lentiginous melanoma (ALM) is the rarest, comprising only 4–10% of melanoma cases, and typically arises on the palmar and plantar surfaces [3] . Subungual melanoma (SUM), a subclass of ALM, is more prevalent in individuals with darker skin, accounting for 10–23% of cutaneous melanomasin Asians, 25% in African-Americans, and 0.18–2.8% in Europeans. It originates from the nail matrix, may extend to the periungual skin through","cbCaieSfVRhTHKAg","https://ap.wps.com/l/cbCaieSfVRhTHKAg","pdf",2505121,"English","# Introduction\n## Case Presentation\n## Conclusion","[{\"question\":\"Why is subungual melanoma often hard to diagnose early?\",\"answer\":\"Subungual melanoma is frequently misidentified in early stages as warts, fungal infections, hematomas, or diabetic foot lesions, leading to delayed recognition and worse outcomes.\"},{\"question\":\"What did the case reveal after biopsy and amputation?\",\"answer\":\"Histopathology confirmed ulcerated malignant melanoma at Clark level V with subcutaneous invasion but no bone involvement, and regional lymph node dissection found one metastatic inguinal node (pN1).\"},{\"question\":\"How was the patient treated after disease progression?\",\"answer\":\"The disease progressed to stage IV within 4 months; PET-CT showed hepatic and pulmonary metastases. With negative BRAF status and lack of available immunotherapy, the patient received systemic chemotherapy with carboplatin and paclitaxel.\"}]","Metastatic Subungual Melanoma of the Hallux - A Case Report | PDF",1790758474,18]