#699 What is subungual melanoma? - DOC

#699 What is subungual melanoma?

What is subungual melanoma? Well, that’s what we’re talking about today on the Doc On The Run Podcast.



If you’re a runner and you’re wondering why in the world is this guy talking about something like subungual melanoma? Well, there’s a couple of reasons. Number one, subungual melanoma is actually extremely deadly. You’re not necessarily likely to get it, but there is a reason that this might be pertinent to you as a runner. One of the most popular videos I’ve actually put up is actually about how to tell the difference between dark toenail fungus and melanoma, or a subungual hematoma and melanoma. And melanoma, or everybody’s familiar with this, right? Skin cancer. We have melanocytes, the things that make you tan. They get darker when you tan, when you have sun exposure. They protect you from the sun. But when you have the melanocytes that turn into cancerous cells, it can kill you. And subungual melanoma is actually extremely deadly.

In fact, if you look at the average five-year survivor rate, the survival rate of subungual melanoma, it ranges from 16% to 80%. That means that at best, you got 20% chance of dying if you get this within five years, and if you like that 16% number, that’s not good. That means that you have an 84% chance of being dead within five years if you get it. So you don’t want it. Now, what makes the difference? Why 16% versus 80%? Well, that has to do with early diagnosis. So if you’re a runner and you beat up your nails, this might be interesting to you because believe it or not, subungual, oh, by the way, so subungual, let me write this down so try to make this clear. Sub means under. Ungual refers to the nail, fingernail or toenail. So melanoma just refers to the melanocytes turning into cancerous cells.

A subungual melanoma, it’s under the nail, and it usually looks like a streak or a spot or something. Oftentimes looks like a bruise. Well, this is why it’s relevant for us as runners. Who do you know that’s had a bruise under the nail? Probably you, if you’re a runner. I’ve had lots of them. I still get them, even though I’m a podiatrist and I know what do with my shoes. Sometimes I forget and do the wrong thing just like everybody else, and I beat up my toes. I get a bruise under the nail, but I usually know when that happens. So if I run 16 miles up and down Mount Tam in brand new shoes the very first time, yes, I did that not long ago, by the way, because what a great way to break in a new pair of shoes. And I beat up my feet a little bit. Shocker. Shocking, I know. But we all do it. We all make mistakes. We all do things we shouldn’t really do, and then we pay the price.

But if you get a bruise under the nail and you’re confused about whether or not it’s really a bruise or it’s melanoma, that’s bad. But I usually know when that happened. I know when I ran up Mount Tam, and you probably know when you run a marathon and beat up your toes. What really concerns me is when I see somebody who comes in, calls me for an issue and then says, “Well, I don’t know where that came from.” And this did happen to me. I’ve seen it twice. Fortunately, I’ve not seen this a lot, but I’ve seen it twice. The first one, I was actually a student. The guy came into a free clinic in Oakland, and he thought that he had an ingrown toenail. He said he had had a dark streak under there, and then it got really inflamed, and he thought it was an ingrown toenail. It wasn’t. It was subungual melanoma, and he was dead about four months later. That was after they amputated his toe, by the way. That didn’t even fix it.

Second guy was a guy who was in his 40s, came into the office, he was a runner. He had some issues not related to this at all. And I said, “How long has that streak been there?” And he said, “Yeah, my wife wanted me to get that checked out, but that’s not why I’m here. I don’t really care about that.” And I went and got a form that had basically, he had to sign that I said, “You need to sign this if you’re not going to do a biopsy. I think you need to do a biopsy.” He didn’t think it was an issue. He did not remember when this streak started, but he thought it was a bruise. And when we looked at his nail, if you look at the big toe, what it looked like was kind of like this. This is the nail. That’s the lunula, the little white part under the nail. And he had this very well-defined streak in the nail that was pretty uniform. It had a couple little splotchy areas, but it was pretty much just a straight-up streak, straight out the nail.

I said, “This could be subungual melanoma. This could kill you.” And I presented him with a form that said, “I understand I’m about to do something really stupid. Dr. Segler told me to get a biopsy and I’m refusing, and I’m not going to hold him responsible if I die a horrible death because I ignored this.” And he then agreed to get a biopsy. We went to the operating room and I did what’s called a punch biopsy. So I literally took a big round instrument called a punch, went all the way through all the way to bone, took out the entire sample and sent it in a pathologist.

I got a report back. The dermatologist, dermatopathologist, actually not dermatologist, dermatopathologist actually called me on my phone. Never a good sign. He was all excited, and he said, “This is subungual melanoma inside too. You actually got all of it.” And so by a stroke of luck, I literally got all of it out in that biopsy. So that’s where better to be lucky than good comes in because I was just plain lucky. I assumed that we would have to take more tissue later, but it had clear margins all the way around it. He was fine, but it definitely would’ve killed him. And so he had to continue to follow up with an oncologist later to make sure it didn’t turn into a thing. But this is what it looks like. It’s just a streak and you’ve got to biopsy it.

What’s also interesting is that when you look at the nail from the side where this is the nail plate sitting up there on top of the toe, and you have the distal phalanx bone sitting in here, you have the lunula is out here, and you have matrix back here too. So this lunula actually makes the nail, makes part of the nail. And so when you actually remove a nail, if the streak is mostly on the top of the nail in cross-section, then that means that it probably came from here. Whereas if you take off the nail and the streak in the nail is down lower, that’s actually probably from the lunula here. So the dermatopathologist can actually actually tell kind of which part of the matrix or root of the nail the melanoma came from, depending upon the location within the nail plate itself. But you’ve got to check it out.

If you get a streak and it’s linear like that, and you don’t know when it started, but it’s new, that’s a bad sign. You should get it checked out. You also have to remember, this is because of trauma. When I was a kid, I actually was taking an archery course, and I remember very clearly I was only 9 or 10 years old, but I remember very clearly the instructor was telling us that when using a compound bow, which is very powerful kind of bow, that you had to wear this thing on your arm that covers your forearm with leather and padding so that if you mess up when you let go, that the string on the bow doesn’t hit your arm over and over.

He said if you hit your arm over and over and over when you’re doing archery, that that actually can cause changes in the cell that can lead to cancer. And that’s what happens with subungual melanoma. So although there’s no real prevention, one of the things that’s recommended in a lot of medical journals and stuff is trying to avoid beating up your toes. Well, we’re runners. That’s where this is relevant for you. So I beat up my toes a lot. I’m a podiatrist, and I think about it, and I try not to beat up my toes. Yet I still do because I like to run a lot and I like to run on trails and street rough trails are actually worse.

Trying to avoid the things that make your toes turn black and blue is helpful, but just because it turns black and blue, that doesn’t mean you have cancer. It’s when you have these weird streaks. If you have a weird nodule, you have flaking in the nails, you have things that are irregular, something that hasn’t been there before, get it checked out by a podiatrist, let them look at it, maybe even biopsy it, but you don’t want to miss it. Remember, there’s a huge difference between a 16% survival rate and an 80% survival rate. 80% is better than 16%. Those people, generally speaking, are going to be the people who have had earlier diagnosis and get it checked out sooner.

So don’t send me pictures of your toes. I don’t care. I’m not going to make a diagnosis by a YouTube comment or in my email. So see somebody and get it checked out if you have this as a concern, but keep track of it. As always, you can take pictures, monitor it, and then that’s really useful when you go see a doctor. If you have something that’s weird and you have pictures from long ago, it’s extremely helpful.

If you like this episode, please like it, please share it, and I’ll see you in the next training.


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