Skin Cancer: The Primary Tumors

Wortsman, Ximena; Carreño, Laura; Morales, Claudia

doi:10.1007/978-1-4614-7184-4_9

Ximena Wortsman MD²,
Laura Carreño MD³ &
Claudia Morales MD³

1988 Accesses
7 Citations

Abstract

Skin cancer is the most frequent form of cancer in human beings and the sonographic imaging support of the primary lesion can provide relevant anatomical data that can improve the prognosis of patients and decrease recurrences. The most frequent types of skin cancer are discussed and include basal cell carcinoma, squamous cell carcinoma, and melanoma. Information on the sonographic morphology, contrast-enhanced ultrasound, and sonoelastography of skin cancer is provided. Other types of malignant skin tumors such as dermatofibrosarcoma protuberans, Merkel cell carcinoma, and cutaneous lymphomas are also covered.

How to deal and what to look for in the primary lesion

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Skin Cancer

Ultrasound of Skin Cancer

Skin Cancer

Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Introduction

Skin cancer is the most common form of cancer in human beings, therefore a frequent cause of dermatological consultation. Cutaneous cancer can be categorized into two main types: non-melanoma skin cancer (NMSC) and melanoma. NMSC constitutes up to 95 % of skin malignancies, and melanoma up to 5 %. The most frequent forms of presentations of NMSC are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) [1].

Less common skin malignancies are dermatofibrosarcoma protuberans, angiosarcoma, Merkel’s cell carcinoma, Kaposi’s sarcoma, and cutaneous lymphomas.

The goal of this chapter is to review the sonographic patterns of the most common forms of skin cancer and the role of sonography in the evaluation of these entities.

2 Non-Melanoma Skin Cancer

NMSC (BCC and SCC) is most frequent on areas exposed to the sun, and can be associated with functional and cosmetic problems that can complicate the evolution and prognosis in highly exposed areas of the body. Thus, NMSC presents frequently in facial locations that include the skin of the eyelids, nose, lips, and ears where the cutaneous layers are thin and involvement of cartilage and orbicular muscles may easily occur. Recurrences and multiple locations are not uncommon and can make the management of patients even more difficult. Incomplete excision of primary NMSC lesions has been reported in up to 45.5 % of cases [2].

2.1 Basal Cell Carcinoma

BCC, also called epithelioma, is the most frequent form of cancer among human beings and composes 75–95 % of all skin cancers. It is rarely fatal but could be highly disfiguring [1–3]. Clinically, BCC appears as a slow-growing, painless, erythematous, pearly papule or nodule that usually easily bleeds after minor trauma or may ulcerate (rodent ulcer). These tumors can also mimic a scar on physical examination.

Greater than 70 % of BCC tumors are located on the face, and the most frequent locations are the nose and eyelids [2, 3]. This type of skin cancer rarely metastasizes, although in areas where the skin is thin, there is a significant risk of involvement of deeper layers such as muscle, cartilage, or bone.

BCCs can be separated into several subtypes: superficial or in situ multifocal (15–35 %); diffuse or infiltrative that include morpheaform and micronodular subtypes (4–17 %); nodular, that also include nodulocystic, adenoid, and ulcerative subtypes (45–60 %); and pigmented (1–7 %). There are also other less common histological variants of BCC such as pleomorphic, clear cell, signet ring, granular, infundibulocystic, metaplastic, and keloidal subtypes, among others. Additionally, the different categories can be mixed within the same lesion or the patient may present multiple lesions with more than one subtype. Histologically, BCC is composed of a fibrous stroma and islands of basaloid cells that are dependent cells similar to the basal cells of the epidermis and hair follicles. The cells show indistinct cytoplasmic borders and oval basophilic vesicular nuclei. The nodulocystic subtype shows cysts with abundant mucin and the adenoid variant presents a pseudoglandular appearance. The morpheaform subtype shows narrow epithelial strands compressed by dense fibrous stroma and hyalinization [4] (Figs. 9.1, 9.2, 9.3, 9.4, 9.5, 9.6, and 9.7).

2.2 Squamous Cell Carcinoma

Cutaneous SCC is the second most common skin cancer, accounting for 20% of all cutaneous malignancies. Most of the tumors are found on the head and neck skin, and cumulative ultraviolet exposure is believed to be the most likely etiological factor. Most deaths from SCC occur in a high-risk group of patients that is composed of tumors greater than 2 cm in diameter; tumor thickness over 4 mm; moderately/poorly differentiated or desmoplastic histological SCC subtype; ear, lip, hand, feet, or genital tumor site; perineural or lymphovascular invasion; nodal metastasis at presentation; recurrent SCC; SCC arising from scars or chronic skin disease, for example, chronic ulcers; and SCC arising in immunosuppressed patients [5]. Furthermore, thickness (or depth of invasion) is an important predictor of metastases in SCC [6]. Thus, ultrasound may support identification of the high-risk SCC group that is associated with a greater mortality and morbidity.

Additionally, there are SCC-related lesions: Bowen’s disease, the in situ form of SCC, and actinic keratosis, a precancerous skin lesion that usually appears in photodamaged skin that potentially can become a squamous cell cancer.

SCC presents clinically as a slow-growing usually painless, indurated lesion with a rough, scaly, erythematous surface that easily bleeds and can be nodular, ulcerated, plaque-like, or verrucous. The ulceration can present with a necrotic center and a prominent rim. Common locations are the lips, ear pinna, scalp, and dorsal aspect of the hands. Hence, infiltration of the deeper layers and metastasis is more frequent with SCC. Metastasis can occur to the regional lymph nodes and also to the liver, bones, lungs, and brain.

Histologically, SCC presents as infiltrating sheets and islands of variably differentiated squamous epithelium and a variable degree of mitotic activity (pleomorphism). Keratocysts and keratin pearls may also be found, with neurotropism and lymphovascular invasion providing poor prognosis. There are variants of SCC such as clear cell SCC, spindle cell, desmoplastic acantholytic, pseudovascular or pseudoangiosarcomatous, adenosquamous, mucoepidermoid, and verrucous [7] (Figs. 9.8, 9.9, 9.10, 9.11, and 9.12)

2.3 Staging of NMSC

Current staging of NMSC is based on the clinical measure of the tumor size, depth, loco-regional lymph node involvement, and distant metastasis. Tumors measuring ≥2 cm on the lips, ear, eye, or nose present a poor prognosis.

Not formally included among high-risk NMSC lesions are the ones present in immunosuppressed patients who show a higher incidence of NMSC under long-term immunosuppressive therapy or conditions. Thus, renal transplantation is associated with an increased incidence of NMSC caused by immunosuppressive treatments, and under this context, NMSC exhibits more aggressive biological and clinical courses, with higher rates of recurrence and mortality than in the general population. In renal transplants, SCC represents the most frequent skin malignancy (64.1 %), followed by BCC (17.9 %), Bowen’s disease (10.2 %), basosquamous carcinoma (5.1 %), and a rare case of invasive sebaceous carcinoma (2.6 %) according to some reports [8, 9]

SCC is the most severe complication and most common cause of death in patients with junctional and recessive dystrophic epidermolysis bullosa [10, 11].

The inclusion of the sonographic parameters (diameter in all axes, blood flow, presence of deeper layers involvement and satellite lesions) may support the clinical staging of NMSC providing valuable data that can match the anatomical involvement for each patient. The latter features may help to perform a one-time treatment, decreasing the possibility of recurrences and improving the cosmetic prognosis of the patient.

2.4 NMSC Sonographic Characteristics

NMSC usually presents as hypoechoic and heterogeneous cutaneous tumors with irregular borders. Hyperechoic spots are frequently detected within BCC tumors. Low flow arterial vessels are commonly detected in the lesion and its periphery. The vascularity in BCC is commonly prominent at the bottom of the tumor [12, 13]. Nevertheless, squamous carcinoma is more aggressive upon presentation, therefore, infiltration of the deeper structures and/or loco-regional lymph nodes should be ruled out on the ultrasound examinations. Vascularity in SCC is frequently more prominent compared with BCC and shows greater presence of vessels within the lesion.

Two sonographic artifacts have been reported in BCC lesions. The first is termed the “angles at the bottom” of the lesion, which is produced by inflammatory components that include dilated vessels and giant cells. The second is termed the “blurry tumor” which is generated by a large presence of hyperplastic sebaceous glands that are isoechogenic with the primary lesion and can decrease the definition of the borders of the tumor [12].

2.4.1 Tips for BCC

Well defined
Hypoechoic
Hyperechoic spots within the tumor
Increased vascularity at the bottom of the lesion

2.4.2 Tips for SCC

Hypoechoic lesion with irregular borders
Involvement of deeper layers
Increased vascularity within the tumor

3 Primary Cutaneous Melanoma

Primary cutaneous melanoma is the most aggressive type of cutaneous malignancy and constitutes 4–11 % of all skin cancers comprising greater than 75 % of cutaneous cancer-related deaths and provoking greater than 8,000 deaths per year in the United States [14]. Recurrence has been reported in up to 35.9 % of the treated cases, and can be even higher (46.1 %) when the head and neck region is considered [15, 16]. Melanomas usually present clinically in 95 % of the cases as hyperpigmented macules or nodules that can show irregular borders and ulcerations. Approximately 5 % of melanomas lack pigment and are called amelanotic melanomas. Amelanotic melanomas contain few and/or deeper granules of melanin that are commonly not detected by the naked eye which can delay diagnosis.

The staging of melanoma is based on the Breslow classification that relies on the sequential tumor infiltration (depth) of the cutaneous layers detected by histology which considers the measurement of the microscopic invasion from the stratum granulosum of the epidermis to the deepest portion of the tumor (Table 9.1) [17]. Thus, knowledge of the thickness of the tumor will modify important decisions pertaining to the management of the tumor, such as the size of the excision, the performance of a sentinel node procedure, or the final prognosis of the patient.

Table 9.1 Clark classification of the levels of invasion in melanoma

Full size table

On histology, melanomas appear as nests of atypical melanocytes with irregular nuclei, nuclear pleomorphism, prominent nucleoli, spindle or epitheliod cells, and marked mitotic activity. The level of invasion is graded according to the Clark classification (Table 9.1) and the depth of the invasion is assessed using the Breslow index (Table 9.2), which are important prognostic factors for melanoma [18].

Table 9.2 Breslow classification of the depth of melanoma

Full size table

On sonography, melanomas usually appear as well-defined, oval- or fusiform-shaped, homogeneous, hypoechoic lesions with smooth borders, increased acoustic transmission, and variable degrees of vascularity, even though they commonly show hypervascularity on color Doppler imaging [19–25]. Sonography has been proved useful for discriminating melanomas thicker and thinner than 1 mm which is relevant for deciding the performance of a sentinel node procedure that is indicated in melanomas that measure greater than 1 mm in thickness [26], the vessels are commonly located within the lesion and may also be tracked using contrast-enhanced ultrasound. Assessment of the vascularity, including the peak systolic velocity of the arterial vessels, may provide an idea of the angiogenic power of the tumor that can correlate with the metastatic potential [27–29]. In cases with ulcerations, the epidermis can show irregularities or discontinuities, and increased echogenicity in the subcutaneous tissue may also be found. Because melanomas can show asymmetry in their thickness, the sonographic measurements should be performed at the deepest point. In the vicinity of the primary lesion, satellite lesions (arising within 2 cm from the primary tumor) or in transit metastasis (arising greater than 2 cm from the primary tumor) can be detected [24, 29, 30]. These secondary lesions appear as hypoechoic oval- or round-shaped with smooth or lobulated contours, mild to moderate heterogenicity, and enhanced acoustic through transmission structures frequently located in the subcutaneous tissue and with variable degrees of vascularity [18, 24, 31]. Ultrasound has been reported to alter the management of patients by detecting impalpable metastasis and helping to differentiate between benign and malignant masses [16, 31]. Usually, there is increased vascularity within the metastases on color Doppler imaging, although the presence of internal vessels can show a variable appearance that can go from hypo- to hypervascular. Occasionally, these metastases can present an irregular appearance and anechogenicity and can be sonographically misdiagnosed as abscesses. This challenging anechoic appearance has been reported as related more to hypercellularity and not as a result of necrosis [32]. The balloon shape, nodular thickening of the cortex, and loss of hyperechogenicity of the medullae are signs of malignant infiltration in regard to nodal infiltration [24]. The use of lower frequency probes in bulky primary melanomas may help to reach to the bottom of the lesion and provide a better definition of the extension (Figs. 9.13, 9.14, 9.15, 9.16, and 9.17).

3.1 Contrast-Enhanced Ultrasound in Melanoma

Intravenous contrast medium, conformed by gas-filled microbubbles that enhance the echogenicity of the vessels, has been progressively used in melanoma and loco-regional staging for obtaining early information about the effectiveness of the treatment of the primary lesion and clarifying a doubtful cortical thickening at the lymph nodes [27–29]. It is also a promising tool to reduce the number of patients who should undergo fine-needle aspiration cytology of lymph nodes with focal cortical thickening in melanoma [33, 34]. The vascular density in melanoma has already been correlated with metastatic potential using color Doppler ultrasound. Thus, neovascularization has been reported as a prognostic factor for metastasis equivalent to the Breslow index [35]. Furthermore, contrast-enhanced ultrasound imaging of tumor neovascularity has been mentioned in the literature as providing a noninvasive marker of angiogenesis corresponding to the expression of vascular endothelial growth factor in mice that were implanted with the human melanoma cell line DB-1 that can become a useful tool for monitoring clinical anti-angiogenic therapies [36]. Lymphosonography (i.e., contrast-enhanced ultrasound after interstitial injection of a contrast agent) has been reported as statistically better than lymphoscintigraphy for the detection of sentinel lymph nodes in an animal model [37].

The limitations of the usage of contrast medium are the current short-life time of the bubbles within the systemic circulation that commonly provides minutes for performing the analysis, the cost, and the invasive nature of the intravenous injection. Nevertheless, lymphosonography can require seconds to identify the movement of the contrast within lymphatic channels and present a higher spatial resolution than lymphoscintigraphy. The sonographic signs for malignancy in lymphosonography are heterogenous or sparse enhancement in sentinel lymph nodes. In contrast, uniform enhancement in small (<5 cm) sentinel lymph nodes suggest benignancy [37]. Thus, contrast-enhanced ultrasound can improve the management of melanoma by allowing detection and characterization of the primary and secondary lesions, guidance of biopsy, and prompt assessment of the effectiveness of the pharmacodynamic response [31].

3.2 Elastography in Cutaneous Melanoma

As of yet, few reports that show the experience or usefulness of sonoelastography in cutaneous melanoma are available [38, 39]. There are reports on acousto-optical elastography, an experimental imaging modality for quantifying the mechanical behavior of skin lesions. The method relies on stimulating the tissue with a low frequency acoustic force and imaging the resulting strains in the tissue by means of quantifying the magnitude of the dynamic shift in a back-reflected laser speckle pattern from the skin. The magnitude of the shift reflects the local stiffness of the tissue, which has shown promising results when comparing benign melanocytic nevi with melanoma [40]. However, to date there are no reports that have altered management in terms of detecting undisclosed malignancies, although it may increase the diagnostic confidence of less-experienced operators performing ultrasound. Therefore, the assessment of the role of elastography in melanoma and other cutaneous tumors probably will require further investigation [37].

3.3 High-Intensity Focused Ultrasound in Cutaneous Melanoma

High-intensity focused ultrasound (HIFU) is a focused sonic energy that heats and destroys the tissue through thermal ablation. Currently, scarce reports on the effects of HIFU in melanoma are available. However, significant tumor necrosis and absent local serum-vascular endothelial growth factor have been described in animal models [41, 42].

3.3.1 Tips for Melanoma

Hypoechoic
Fusiform lesion
Increased vascularity
Check for satellite (≤2 cm from the primary tumor), in-transit (≥2 cm from the primary tumor), or nodal metastasis
Provide extension in all axes

4 Other Malignant Skin Tumors

4.1 Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is an unusual, locally aggressive cutaneous fibroblastic neoplasm that mainly affects the torso and proximal extremities of young and middle-aged adults. DFSP presents as a slow-growing, multinodular, and plaque-like erythematous or purple mass that tends to infiltrate and show local recurrence but rarely metastasizes to distant organs [43].

On histology, there is a proliferation of spindle cells with elongated nuclei with little or no pleomorphism. DFSP usually affects the dermis and subcutaneous tissue although it can also involve deeper layers. Inmunohistochemical markers such as CD34 are commonly positive [43, 44]. On sonography, two sonographic patterns have been described The first is a well-defined oval hypoechoic structure and the second is composed of an ill-defined heterogeneous structure, with hyper- and hypoechoic areas and lobulated or pseudopodia-like protrusions commonly affecting the dermis and subcutaneous tissue. DFSP can also send projections to the fascial or muscular layers. Nevertheless, this condition usually tends to spread horizontally, and the degree of vascularization is variable but commonly presents slow flow vessels [45, 46] (Figs. 9.18 and 9.19).

4.2 Cutaneous Angiosarcoma

Cutaneous angiosarcoma is a rare malignant tumor of endothelial origin that often presents an aggressive course, with 60 % of angiosarcomas primarily located in the skin and mainly affect older patients (>50 years of age) with a peak incidence in the eighth decade. The 5-year survival rate ranges from 12 % to 20 % and angiosarcoma often undergoes distant metastasis most commonly in the liver, lymph nodes, and spleen. The most important prognostic feature is tumor size, and other significant factors are depth of invasion >3 mm, mitotic rate, positive surgical margins, local recurrence, and metastases.

The head and neck form of angiosarcoma is the most frequent subtype, also called idiopathic angiosarcoma, and accounts for 50–60 % of all cases. The latter form is frequently seen on the scalp of elderly men.

Clinically, angiosarcomas show as a bruise-like erythematous or violaceous plaques or mass that becomes larger and ill-defined over time. Pain, bleeding, and swelling have been also described. A higher incidence of angiosarcomas occurs in female patients that have received radiation therapy for breast cancer, patients that present with chronic extremity lymphedema (Stewart-Treves syndrome), and pre-existing vascular malformations have been reported [47, 48].

Histologically, the masses consist of ill-defined hemorrhagic and occasionally blood-filled cystic spaces. The cutaneous layers and sometimes deeper structures are commonly replaced by a diffuse, irregular, and anastomosing network of endothelial-lined erythrocyte containing variably slit-like to medium-sized sinusoidal to larger blood-filled cystic spaces. The endothelial cells are enlarged and contain hobnailed hyperchromatic round to oval nuclei with condensed chromatin. Other forms show a solid pattern with epithelioid and spindle cells with little intervening stroma [49–51].

On sonography, angiosarcoma appears as an ill-defined or lobulated hypoechoic mass with prominent vascularity commonly with low flow arterial and venous vessels. This tumor usually infiltrates the dermis and subcutaneous tissue but can also affect deeper structures. (See Fig. 8.10.)

4.3 Kaposi’s Sarcoma

Kaposi’s sarcoma (KS) is a low-grade mesenchymal tumor involving blood and lymphatic vessels. There are four variants of the disease, each presenting a different clinical manifestation: classic or sporadic, African or endemic, organ transplant-related or iatrogenic, and AIDS-related or epidemic. This condition is the most common tumor among patients with HIV infection [52]. KS is a low-grade malignancy that is associated with human herpesvirus-8, and composes a multifocal tumor that most commonly affects mucocutaneous sites. It might also involve lymph nodes and visceral organs, in particular of the respiratory and gastrointestinal tract, but it can affect every organ system [53].

Histologically, in its early stages, KS contains blood vessels with a fine endothelium passing through the dermal collagen bundles. In the plaque and nodular stages, the vessel lumens are visible more clearly and there is a progressive increase in the number of neoplastic spindle cells with a low degree of pleomorphism and atypia, and occasional mitoses. The infiltrate is made up of lymphocytes and plasma cells [54].

On sonography, KS lesions appear as hypoechoic or heterogeneous lesions, as a plaque-like thickening of the dermis, sometimes with a nodular appearance. Vascularity is variable within the lesion and infiltration of deeper structures, such as muscles, has been reported [55]. Ultrasound has been used as an objective tool for measuring the degree of remission of the disease [56, 57] (See Fig. 8.11).

4.4 Merkel Cell Carcinoma

Merkel cell carcinoma (MCC) originates from a cutaneous mechanoreceptor cell (Merkel cell) located in the basal layer of the epidermis [58]. MCC is a rare neuroendocrine carcinoma of the skin that is found primarily in older individuals and exhibits a bad prognosis mainly because of a high rate of local recurrence. Risk factors associated with the development of MCC include exposure to ultraviolet radiation and immunosuppression, with a viral etiology (polyomavirus) also being proposed. Thirty-six percent of cases of MCC are located on sun-exposed areas such as the face and 50 % are located on the head and neck.

MCC presents clinically as a single firm flesh-colored to erythematous dome-shaped nodule with a smooth shiny surface, sometimes with telangiectasia.

Regional lymph nodes are involved in 15–66 % of patients and distant metastases are found in 1–6 % of patients.

Histologically, MCC appears as a dermal nodule or plaque that frequently extends into the subcutaneous tissue. It may show a nodular or infitrative pattern with lymphovascular invasion. Small blue cells with basophilic nuclei and minimal cytoplasm are detected. Mitoses are frequent and apoptosis index is high. Inmunohistochemistry using CK (cytokeratin)-20 positive and thyroid transcription factor-1 negative may help to assess the diagnosis, among other markers.

Tumor size ≥2 cm, lymph node involvement, deeper structure involvement (muscle, fascia or cartilage), infiltrative pattern on histology, and distant metastasis (liver, lung, bone, brain) present a worse prognosis [59].

On sonography, MCC tumors will present as a hypoechoic ill-defined nodule or mass that usually affects the dermis and subcutaneous tissue and presents prominent vascularity (Fig. 9.20).

4.5 Cutaneous Lymphoma

Cutaneous lymphoma comprises a heterogeneous group of lymphoproliferative cutaneous disorders separated mainly by the predominant type of lymphoid cell present in the tumor. Hence, they can be classified into two groups: T-cell and B-cell lymphomas [60]. The most common type of T-cell lymphomas are mycosis fungoides, named for its mushroom-like tumors that are commonly seen at the end stage of the disease and Sezary’s syndrome, a leukemic erythrodermic lymphoma variant. The three major histological subgroups of primary cutaneous B-cell lymphoma are: follicle center, marginal zone B-cell, large B-cell and leg type.

4.5.1 Mycosis Fungoides

Mycosis fungoides is the most frequent form of primary cutaneous T-cell lymphoma that is a low-grade cutaneous lymphoma characterized by skin-homing CD4+ T cells. Clinically, it shows highly symptomatic progressive skin lesions including patches, plaques, tumors, scaling, poikiloderma, and erythroderma, and has a poorer prognosis during later stages [61].

Histologically, mycosis fungoides presents as hyperkeratosis, psoriasiform hyperplasia, and superficial perivascular lymphocytic infiltrates. Scarring and atypical lymphocytes with hyperchromatic nuclei can also present.

Folliculotropic mycosis fungoides (FMF) is a variant of cutaneous T-cell lymphoma that affects the hair follicles.

4.5.2 Sezary’s Syndrome

The leukemic form of Sezary’s syndrome is most common in the fifth to seventh decades of life and is characterized by intense pruritus, edema, scaling (especially in the palms and soles [palmoplantar keratoderma]), and a generalized infiltrative erythroderma. Lymphadenopathy and atypical circulating lymphocytes (Sezary’s cells) in the peripheral blood are also commonly found.

Histologically, Sezary’s syndrome shows infiltrates composed of highly convoluted cerbriform lymphocytes with hyperkeratosis, acanthosis, and sometimes microabscesses.

4.5.3 Subcutaneous Panniculitic T-Cell Lymphoma

Subcutaneous panniculitic T-cell lymphoma is a less common form of presentation of T-cell lymphoma that can clinically mimic chronic panniculitis and present as multiple ulcerated and erythematous or violaceous nodules or plaques that most commonly affect the torso and extremities. Histologically, panniculitic T-cell lymphoma presents with vesicular and hyperchromatic nuclei and conspicuous erythrophagocytosis. The atypical lymphocytes involve the subcutaneous tissue and rim fat cells with a lace-like appearance. Fat necrosis with xanthoma cells and hemorrhage are also commonly found.

4.5.4 B-Cell Cutaneous Lymphomas

B-cell cutaneous lymphomas cab be either primary or metastatic. The marginal zone B-cell lymphoma is the most common primary cutaneous type. Clinically, this type shows as single or multiple asymptomatic, erythematous, brown or violaceous papules, nodules, or plaques sometimes surrounded by an erythematous border. The torso, especially the back, is the most affected area. In contrast to mucosae, the skin does not have an associated B-cell lymphocyte population, therefore it has been suggested that skin-associated lymphoid tissue may develop following chronic antigen stimulation, such as chronic inflammation or autoimmune diseases. Histologically, there is a dense atypical B-cell lymphoid infiltrate in B-cell cutaneous lymphoma that dissects the collagen with inmunoblasts that present central eosinophilic nuclei and scattered eosinophils [62].

On sonography, lymphomas can present as focal hypoechoic or heterogeneous thickening of the dermis or as diffuse lesions that involve the dermis and subcutaneous tissue. The diffuse form of presentation usually appears as heterogeneous involvement with mixed echogenicity (anechoic, hypoechoic, and hyperechoic areas). When the lesions are anechoic, they can mimic fluid collections. Diffuse forms of presentation may show single or multiple locations and anechoic or hypoechoic plaque-like structures. Subcutaneous panniculitic T-cell lymphoma (STCL) can present with prominent and hyperechoic fatty lobules as well as anechoic or hypoechoic septa in the subcutaneous tissue. The latter form of presentation (STCL) may mimic cellulitis. The vascularity is variable and can go from hypovascular to hypervascular (63, 64) (Figs. 9.21, 9.22, 9.23, and 9.24).

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Authors and Affiliations

Department of Radiology and Dermatology, Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Clinica Servet, University of Chile, Faculty of Medicine, Almirante Pastene 150, Providencia, Santiago, Chile
Ximena Wortsman MD
Department of Pathology, Dermopathology Section, Hospital Clinico Universidad de Chile, Faculty of Medicine, University of Chile, Santiago, Chile
Laura Carreño MD & Claudia Morales MD

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Ximena Wortsman MD
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Laura Carreño MD
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Claudia Morales MD
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Correspondence to Ximena Wortsman MD .

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Clinica Servet, Faculty of Medicine, University of Chile, Almirante Pastene 150, Santiago, 7500551, Chile
Ximena Wortsman

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Wortsman, X., Carreño, L., Morales, C. (2013). Skin Cancer: The Primary Tumors. In: Wortsman, X. (eds) Dermatologic Ultrasound with Clinical and Histologic Correlations. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-7184-4_9

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DOI: https://doi.org/10.1007/978-1-4614-7184-4_9
Published: 17 May 2013
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4614-7183-7
Online ISBN: 978-1-4614-7184-4
eBook Packages: MedicineMedicine (R0)

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Skin Cancer: The Primary Tumors

Abstract

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Skin Cancer

Ultrasound of Skin Cancer

Skin Cancer

Keywords

1 Introduction

2 Non-Melanoma Skin Cancer

2.1 Basal Cell Carcinoma

2.2 Squamous Cell Carcinoma

2.3 Staging of NMSC

2.4 NMSC Sonographic Characteristics

2.4.1 Tips for BCC

2.4.2 Tips for SCC

3 Primary Cutaneous Melanoma

3.1 Contrast-Enhanced Ultrasound in Melanoma

3.2 Elastography in Cutaneous Melanoma

3.3 High-Intensity Focused Ultrasound in Cutaneous Melanoma

3.3.1 Tips for Melanoma

4 Other Malignant Skin Tumors

4.1 Dermatofibrosarcoma Protuberans

4.2 Cutaneous Angiosarcoma

4.3 Kaposi’s Sarcoma

4.4 Merkel Cell Carcinoma

4.5 Cutaneous Lymphoma

4.5.1 Mycosis Fungoides

4.5.2 Sezary’s Syndrome

4.5.3 Subcutaneous Panniculitic T-Cell Lymphoma

4.5.4 B-Cell Cutaneous Lymphomas

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