The contribution of high-resolution ultrasonography in preoperatively detecting sentinel-node metastases in melanoma patients.

To evaluate the ability of high-resolution ultrasonography (hrUS) to detect sentinel-node (SN) melanoma metastases preoperatively before sentinel-node biopsy (SNB), to define hrUS resolution, and to evaluate which US criteria should be used. During a 6.5-year period, 131 consecutive patients with 132 >or=1-mm thick or ulcerated cutaneous melanomas, who were followed up at a single center, were enrolled. All patients underwent preoperative regional lymph-node hrUS and SNB. We used the recently evaluated ultrasonographic stringent and nonstringent hrUS criteria to detect SN metastases. Sizes of the SN metastatic deposits were measured under light microscopy. Thirty-five (27%) patients had a positive SNB. HrUS identified only three positive SNs as being metastatic. Sensitivity and specificity using stringent criteria were 8.8% [95% confidence interval (CI, 2.3-24.8%) and 95.9% (95% CI, 89.3-98.7%)], respectively. Positive-predictive value was 42.9% (95% CI, 11.9-79.9%). The nonstringent criteria provided four additional true-positive results, but lowered specificity (89.8%; 95% CI, 81.6-94.7%) with no significant improvement in sensitivity (20.6%; 95% CI, 9.3-38.4%). Positive-predictive value using nonstringent criteria was 41.2% (95% CI, 19.3-66.4%). HrUS failed to detect all metastatic deposits <5 mm in diameter. HrUS assessment of early-stage melanomas cannot replace surgical SNB. Owing to its low positive-predictive value, hrUS was unable to identify patients who would have to proceed directly to completion lymphadenectomy.

Ultrasonography using simple diagnostic criteria vs palpation for the detection of regional lymph node metastases of melanoma.

OBJECTIVES: Our aims were (1) to compare the respective ability of ultrasonography and palpation to detect nodal metastasis during initial staging and follow-up in patients having melanomas and (2) to assess, we believe for the first time, which ultrasound criteria should be used to define metastasis in cases of cutaneous or mucosal melanoma. DESIGN: Prospective single-center study. Nodal metastasis was confirmed by histopathologic evaluation. SETTING: Dermatology and radiology departments of a university hospital. PATIENTS: A total of 160 new consecutive patients with stage I to stage III melanoma. INTERVENTION: Experienced operators independently performed 391 paired palpation and ultrasonographic examinations. MAIN OUTCOME MEASURES: Firm enlarged nodes found on palpation were considered metastatic. On ultrasonographic examination, circular or oval hypoechoic lymph nodes lacking hyperechoic hila were considered metastatic (stringent criteria). Nodes with 2 or fewer of these patterns and other published signs of metastasis (ie, intranodal nodular hypoechoic focus and irregularity of the node margin) were considered suspicious. RESULTS: Over the 6-year study period 33 patients developed nodal metastasis. For palpation and ultrasonography using the stringent criteria, respectively, sensitivity was 41.5% (95% confidence interval [95% CI], 29.6-53.5) and 76.9% (95% CI, 66.7%-87.2%) (P<.001) and specificity was 95.7% (95% CI, 93.5%-97.9%) and 98.4% (95% CI, 97.1%-99.8%) (P<.05). Including ultrasonographically suspicious lymph nodes significantly lowered specificity (86.2% [95% CI, 82.5-89.9]) (P<.05) without improving sensitivity. Previous lymphadenectomy had little impact on ultrasonographic findings. CONCLUSION: Ultrasonography using stringent criteria of nodal metastasis, which are easy to identify and reliable, is superior to palpation for early detection of regional lymph node metastases of melanoma.

Ultrasonography or palpation for detection of melanoma nodal invasion: a meta-analysis.

Because treatment of distant melanoma metastases is not very effective, nodal spread should be diagnosed early so that therapeutic lymphadenectomy can be started as early as possible. Physical examination alone often does not detect nodal metastases and palpable nodes cannot be clasified unambiguously. Whether lymph-node ultrasonography-an inexpensive procedure-improves detection of nodal invasion during the initial staging and follow-up of patients with melanoma is controversial. We used meta-analysis techniques for diagnostic tests to assess the merit of ultrasonography and palpation in detection of nodal invasion in patients with melanoma. Five databases were screened until December, 2003. 12 studies, including 6642 patients and 18?610 paired palpation and ultrasound examinations, were eligible. The main limitations were variations in the definition of false negatives, and verification bias. Ultrasonography had a higher discriminatory power (odds ratio 1755; 95% CI 726-4238) than did palpation (21 [4-111]; p=0.0001). Furthermore, positive-likelihood ratios were 41.9 (95% CI 29-75) for ultrasonography and 4.55 (2-18) for palpation; negative-likelihood ratios were 0.024 (0.01-0.03) and 0.22 (0.06-0.31), respectively. Our results showed clearly that ultrasonography detects lymph-node invasion more accurately than palpation, and should therefore probably be used routinely in patients with melanoma.