Abstract
In this chapter, we review the ultrasound appearance of the most common types of skin cancer. Ultrasound supports the detection and assessment of the extent, besides discriminating some subtypes.
Ultrasound is a technique that allows us to know the real depth of the primary skin tumor and its vascularity patterns, which is a big difference and a tremendous advance compared to other imaging techniques.
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Keywords
- Skin cancer ultrasound
- Dermatologic ultrasound
- Basal cell carcinoma ultrasound
- Squamous cell carcinoma ultrasound
- Melanoma ultrasound
- Dermatofibrosarcoma protuberans ultrasound
Introduction
One of the main advantages of ultrasound is the possibility of evaluating skin cancer [1,2,3,4,5]. The role of ultrasound is to support the detection of the primary tumor and its extent in all axes, including depth, as well as the performance of locoregional staging [1,2,3,4,5,6]. This is relevant because, so far, ultrasound is the only imaging technique that can define the depth of the tumor without penetration issues [1,2,3,4,5,6,7]. In contrast, dermoscopy, confocal microscopy, and optical coherence tomography are limited by the penetration of the light that can make difficult the observation of the deep border in tumors thicker than 200 μ or 2 mm according to the technique [1,2,3]. On the other hand, PET-CT and MRI present a lower axial spatial resolution in comparison with ultrasound at ≥15 MHz [1,2,3, 8,9,10]. The latter point is relevant because not all ultrasound devices are useful for performing studies of the primary tumor or their locoregional staging. Indeed, there are minimum requirements for performing the examinations, including a proper device and a trained operator [11, 12]. The lack of these factors may decrease the sensitivity of the detection [11, 12]. Moreover, the quality of the ultrasound devices is also an important point because devices older than 5 years may not be comparable with new machines. These features may explain why some reviews or reports do not consider ultrasound as an accurate imaging modality for studying skin cancer. Usually, in these cases, there are non-recommended or unclear ultrasound devices and a lack of trained operators [13].
Thus, to date, ultrasound is the first imaging modality to observe and measure the primary tumor, including all axes, and perform a locoregional staging [1,2,3, 6, 14, 15].
Skin cancers can be separated into non-melanoma and melanoma [3, 4, 6]. The most common non-melanoma skin cancers are basal cell carcinoma and squamous cell carcinoma [3, 4, 6]. Other less common types of non-melanoma tumors include dermatofibrosarcoma protuberans, cutaneous lymphomas, Merkel cell tumors, and liposarcomas [3, 4].
Even though the most common types of non-melanoma skin cancers are usually not lethal, they can generate important disfiguration and strongly affect the self-esteem of individuals [1,2,3,4, 16].
This chapter reviews essential concepts on the ultrasonographic appearance of skin cancer following a practical approach and combining the clinical, ultrasonographical, and histologic features.
Non-melanoma Skin Cancers
Basal Cell Carcinoma (BCC)
Also called basal cell epithelioma or basalioma, this is the most common skin cancer in humans and commonly affects the sun-exposed regions such as the face in 85% of cases [1,2,3,4, 16,17,18,19]. On ultrasound, BCC shows a hypoechoic oval or band-like lesion that frequently presents hyperechoic spots and affects the dermis and sometimes the hypodermis and deeper layers [1,2,3,4, 6, 14, 16, 18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]. Other less frequent forms of presentation are the asymmetric, hourglass, bulging, butterfly, or irregular shapes [16].
The presence of hyperechoic spots is a vital sign for diagnosing BCC because they have not been reported in squamous cell carcinoma or melanoma. These hyperechoic spots are linked to the risk of recurrence of the BCC histologic subtype [16, 31, 33]. Thus, hyperechoic spots are higher in number (≥7) in the more aggressive subtypes such as micronodular, morpheaform, sclerosing, metatypical, and infiltrative [33].Low-risk-of-recurrence histologic subtypes include macronodular or nodular, superficial, adenoid cystic, and Pinkus fibroepithelioma [33].
Even though some of these hyperechoic spots correspond to calcium deposits and corneum cysts, the majority are not detected in the histological samples studied with hematoxylin and eosin; therefore, it is thought that they are compact nests of neoplastic cells or molecular deposits that generate this ultrasonographic pattern [33]. In dermoscopy, there are multiple aggregates of yellow-white globules in nonpigmented BCC that perhaps may be linked to the hyperechoic spots because a high number of aggregates of yellow-white globules have been reported in high-risk-of-recurrence histologic subtypes of BCC [34].
These hyperechoic spots may also be detected in some cases of trichoepithelioma, a close lesion to BCC [4]. Additionally, the calcifications of chondroid syringomas may present a differential diagnosis, but chondroid syringomas show other morphology and tend to be close to cartilage.
It is not uncommon to find mixed tumors that contain a low- and high-risk-of-recurrence tumors in the same lesion [35]. In these cases, ultrasound can support selecting the best biopsy site besides supporting the diagnosis.
On color Doppler ultrasound, their vascularity is variable and can range from hypovascular to intermediate degree of vascularity [16]. In some cases, there is inflammation surrounding the BCC lesions that may generate a minor overestimation of the size [21], which is, of course, lower when ultrahigh frequency probes such as 70 MHz are used.
The ultrasonographic detection of involvement of deeper layers in BCC is of paramount importance, particularly in the facial lesions that can easily extend into the muscles, such as the orbicularis muscles of the eyelids or the lips and the nasal cartilages. This information is critical for surgical planning because the objective is to provide both oncological and cosmetic good results (Figs. 9.1, 9.2, 9.3, and 9.4) [1,2,3,4, 30,31,32,33, 35].
Squamous Cell Carcinoma (SCC)
Also called spinocellular carcinoma, epithelioma spinocellular, and spinalioma, this tumor is less frequent than BCC but commonly affects similar corporal regions such as the face or the scalp [3, 4, 6, 28, 36]. On ultrasound, they present as focal oval or a band-like hypoechoic dermal structure that can infiltrate the hypodermis and deeper layers and may present lobulated or irregular borders [3, 4, 6, 28, 36]. Commonly, they present epidermal irregularities and thickening. The involvement of muscle and cartilages is more common in SCC in comparison with BCC [3, 4, 6, 36]. Despite the lack of guidelines for studying SCC, performing a locoregional staging in these cases would be relevant because their more aggressive nature can even involve the regional lymph nodes.
Occasionally, SCCs may appear in scar sites and under immunosuppressive conditions, affecting sun-non-exposed corporal regions.
On color Doppler, SCC shows a variable degree of vascularity, but they tend to be more hypervascular than BCCs (Figs. 9.5, 9.6, and 9.7) [3, 4, 6, 36].
Dermatofibrosarcoma Protuberans (DFSP)
This fibrous sarcomatous tumor presents high local recurrence rates and a low risk of metastases [37]. On ultrasound, DFSP generates ill-defined, mixed echogenicity lesions with a dermal hypoechoic cap and hyperechoic pseudopods and sometimes with lobulated borders that infiltrate the hypodermis [3, 4, 38, 39]. DFSP presents ill-defined borders and displaces the epidermis upward, generating a pseudonodular appearance in some cases. Satellite hypoechoic nodules may be detected in the periphery of the primary tumor [3, 4, 38, 39].
DFSP presents an intermediate degree of vascularity on color Doppler ultrasound with low-flow arterial and/or venous vessels (Figs. 9.8, 9.9, and 9.10) [3, 4].
Merkel Cell Tumor
These aggressive malignant neuroendocrine tumors derive from Merkel cells, usually affect older people, and are commonly located in the head. It has a high incidence of local recurrence as well as nodal and distant metastatic disease [40,41,42,43].
The 5-year survival rates are 64% for local disease, 39% for regional nodal involvement, and 18% for distant metastatic disease [42, 43].
On ultrasound, they show as hypoechoic dermal or deeper lesions commonly bulging and highly hypervascular with low-velocity arterial vessels. It is essential to assess the involvement of deeper layers in these cases because it is not uncommon (Fig. 9.11) [40, 41, 44, 45].
Primary Cutaneous Lymphomas
Primary cutaneous lymphomas (PCL) are the second most common extranodal non-Hodgkin lymphomas, and their estimated annual incidence is 1/100,000 in Western countries. PCL differ significantly from nodal lymphomas and primary extranodal lymphomas in other locations because they tend to remain localized to the skin for a long time with a much more indolent course and a much better prognosis than lymphomas of similar histological subtype in other locations.
According to their origin, they can be classified into T cell, B cell, and natural killer (NK) cell. Cutaneous T cell lymphomas (CTCL) are the most frequent type and account for approximately 75–80% of all lymphomas, comprising a heterogeneous group [46,47,48,49,50,51,52].
Among CTCL, mycosis fungoides (MF) is the most common subtype and accounts for approximately 80%. MF originates in the peripheral epidermotropic T cells, specifically the memory T cells (CD45RO+), which express the T-cell receptor (TCR) and CD4+ immunophenotype. There are less frequent subtypes, such as folliculotropic MF (FMF), in which the malignant T cells infiltrate the hair follicle epithelium [46, 47, 49,50,51,52,53].
Primary cutaneous B-cell lymphomas (pCBCL) include an infrequent group of non-Hodgkin lymphomas that are limited to skin sites at the time of diagnosis. This type of lymphoma accounts for approximately 25% and is composed of several subtypes [48, 50,51,52].
Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare primary cutaneous lymphoma composed of cytotoxic alpha-beta T cells that mimics panniculitis [54].
Clinically, they can show plaques, papules, and nodules to mixed cutaneous lesions, from erythematous to violaceous [52, 55].
On ultrasound, lymphomas tend to involve dermis and hypodermis with ill-defined borders. They are commonly hypoechoic and present pseudonodular or nodular hypoechoic areas [4, 52, 55].
In cases with panniculitis-like T-cell lymphomas, there is an increase in the hypodermis’s echogenicity with hypoechoic thickening of the septa, which can indeed simulate a panniculitis [4, 52, 55, 56].
On color Doppler, they tend to present an intermediate to a high degree of vascularity with low-velocity vessels [4, 55, 56].
Among their differential diagnoses are pseudolymphomas, a heterogeneous group of polyclonal reactive lymphoproliferations associated with inflammation. On ultrasound, the borders of nodular pseudolymphomas are usually better defined, and there are [57, 58] hypoechoic globules and teardrop signs within the lesions [59]. Another potential tip for discriminating pseudolymphomas over lymphomas is that in pseudolymphomas, the inflammatory signs (hypervascularity) predominate in the dermis, and their predominant shape is fusiform. In contrast, lymphomas frequently involve the hypodermis, present a higher degree of vascularity than pseudolymphomas, and tend to be ill-defined (Figs. 9.12, 9.13, and 9.14) [59].
Liposarcomas
These malignant mesenchymal tumors are composed of lipoblasts and can present a variable appearance [57, 58, 60, 61]. Liposarcoma is the second most common malignant soft-tissue tumor. This entity is pathologically categorized into four subtypes: well-differentiated, myxoid, dedifferentiated, and pleomorphic.
On ultrasound, it has been reported that malignant signs of transformation of lipomas are size >5 cm, heterogeneous echogenicity, ill-defined borders, and hypervascularity. Well-differentiated liposarcomas have been characterized as isoechoic with tiny hyperechoic lines and hypovascularity. Myxoid liposarcomas present a mix of hypoechoic and anechoic areas with moderate vascularity. Dedifferentiated liposarcomas present a specific biphasic pattern of hyperechoic and hypoechoic areas and hypervascularity. Pleomorphic liposarcomas have been reported to present a specific gyrus-like mixture of hyperechoic and hypoechoic areas (Figs. 9.15 and 9.16) [4, 62].
Melanoma
This malignant tumor derived from the melanocytes is the most lethal form of skin cancer [63]. Importantly, ultrasound can provide the thickness of the melanoma (Ultrasonographic Breslow Index) and support the locoregional staging [3, 4, 64,65,66,67,68,69].
On ultrasound, melanomas are hypoechoic lesions, predominantly fusiform, and involve dermis and/or hypodermis and deeper layers. Nevertheless, in deep melanomas, the shape can be irregular, and there is increased echogenicity of the subcutaneous tissue. Superficial in situ melanomas may not present alterations on ultrasound. If they are located in the acral regions, sometimes they may generate a loss of the epidermal hyperechoic bilaminar pattern. Keep in mind that among the limitations of ultrasound are the detection of in situ lesions and pigments such as melanin [3, 4, 64,65,66,67,68,69].
Frequently, melanomas are hypervascular on color Doppler with low-flow arterial and venous vessels (Figs. 9.17, 9.18, and 9.19) [3, 4, 64,65,66,67,68,69].
Satellite (<2 cm from the primary tumor), in-transit (≥2 cm from the primary tumor), and nodal metastasis can be ruled out with ultrasound [3, 4, 7, 66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85]. The locoregional staging can be performed on ultrasound and starts in the primary tumor or its scar and follows the primary lymphatic drainage regions [3, 4, 7, 67, 69, 70, 72,73,74,75, 80, 81, 83, 84]. Satellite and in-transit metastases show as hypoechoic nodules sometimes with lobulated borders that present an intermediate or high degree of vascularity (Figs. 9.20, 9.21, 9.22, and 9.23). Occasionally, due to the presence of highly cellular nests of tumoral cells, the metastases may show anechoic areas that do not correspond to necrosis and simulate abscesses. Signs of lymph node infiltration are the change of the shape from oval to round, the loss of the medulla with a fully hypoechoic lymph node, the presence of internal asymmetric hypoechoic nodules in the cortex or medulla, and the cortical and chaotic hypervascularity. The size >1 cm has also been reported as suspicious of malignancy; however, this feature should be added to other signs of malignancy (Fig. 9.24) [3, 4, 7, 67, 69, 70, 72,73,74,75, 80, 81, 83, 84].
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Wortsman, X., Pizarro, K., Corredoira, Y., Carreño, L., Morales, C. (2022). Essential Concepts on Ultrasonography of Skin Cancer. In: Wortsman, X. (eds) Textbook of Dermatologic Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-031-08736-3_9
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