Ultrasound technology in dermatology.

As a noninvasive diagnostic method, real-time B-mode sonography belongs to the diagnostic standard procedures in various fields of clinical medicine, for example, internal medicine, gynecology, and otorhinolaryngology. During the past 3 decades, ultrasound technology has been extended to clinical dermatology. High-frequency ultrasound systems with 20- to 50-MHz probes are used for the assessment of tumoral and inflammatory processes of the skin, providing information about their axial and lateral extension. They are of special interest in preoperative situations and for the monitoring of skin conditions under therapy. In contrast to high-frequency ultrasound systems, the value of ultrasound technology with the use of 7.5- to 15-MHz probes generally is not accepted worldwide, although it can be used easily and without significant side effects. Promising results have been reported from specialized diagnostic centers, especially for the assessment of peripheral lymph nodes and soft-tissue tumors. Although it is unable to provide malignancy specific information, ultrasound is nonetheless helpful in the follow-up of patients undergoing, for example, chemotherapy or radiotherapy. The 3-dimensional size and outline of a tumor as well as its relation to surrounding structures like vessels can be described. Moreover, information about the tumor quality (solid, cyst, complex) and the inner structure of a tumor (hypoechoic, hyperechoic, homogenous, inhomogenous, calcification foci, necroses) can be provided. In addition to conventional B-mode-sonography, newer ultrasound techniques like native and signal-enhanced color Doppler sonography as well as ultrasound-guided fine needle aspiration cytology are reviewed.

Ultrasonography in dermatology.

Ultrasonography is an essential tool for most medical specialties; training in its use is required for dermatology residency programs in Germany. Ultrasonography is a versatile, painless, low-risk, non-invasive procedure which can be done anywhere and easily repeated; it provides real-time visual information about benign and malignant processes in the skin and subcutis. High frequency sonography with 20 MHz scanners is well-established for measuring the thickness of the skin or its tumors and assessing inflammatory skin disorders. Mid-frequency sonography with 7.5-15 MHz sounds is widely used in dermatologic oncology, both for pre-operative staging and follow-up of melanoma patients. The interpretation of sonographic images such as borders of lesions, echogenicity, artifacts and vascular patterns with duplex color sonography requires structured education and intensive training. The wide variety of diagnostic information provided by sonography underlines its essential position in certified skin cancer centers.

Repeated botulinum toxin A injections for the treatment of lines in the upper face: a retrospective study of 4,103 treatments in 945 patients.

BACKGROUND: Although botulinum toxin type A (BoNT-A) is a common aesthetic intervention, there are few published data on treatment over more than two cycles. OBJECTIVE: To evaluate the effectiveness/safety of repeated doses of BoNT-A (Dysport, Ipsen Ltd., Slough, UK) in the upper face for reduction of wrinkles. METHODS: Retrospective, cross-sectional patient chart review from 945 patients who had received a minimum of three consecutive, documented treatment cycles. RESULTS: The glabella was treated most frequently (93.9%), with the majority (81.5%) of patients receiving treatment in more than one area of the face. BoNT-A treatments were combined with other aesthetic procedures in 57.5% of cases, mostly with fillers (37.1%). There was no evidence of tachyphylaxia: the dose applied, the interval between treatments, and satisfaction with the results remained stable over the course of treatment. Adverse events were those expected with BoNT-A treatment (most common: local bruising and ptosis) and were all mild or moderate in intensity. There was no sign of any cumulative adverse effects: indeed, the adverse-event rate decreased in later treatment cycles. CONCLUSIONS: Long-term, repeated injections of BoNT-A for corrections of wrinkles in the upper face yield a continuously high level of safety and effectiveness in actual practice.

Ultrasound mapping of lymph node and subcutaneous metastases in patients with cutaneous melanoma: results of a prospective multicenter study.

BACKGROUND: Ultrasound (sonography, B-mode sonography, ultrasonography) examination improves the sensitivity in more than 25% compared to the clinical palpation, especially after surgery on the regional lymph node area. OBJECTIVE: To evaluate the distribution of metastases during follow-up in the draining lymph node areas from the scar of primary to regional lymph nodes (head and neck, supraclavicular, axilla, infraclavicular, groin) in patients with cutaneous melanoma with or without sentinel lymph node biopsy (SLNB) or former elective or consecutive complete lymph node dissection in case of positive sentinel lymph node (CLND). cv: Prospective multicenter study of the Departments of Dermatology of the Universities of Homburg/Saar, Tubingen and Munich (Germany) in which the distribution of lymph node and subcutaneous metastases were mapped from the scar of primary to the lymphatic drainage region in 53 melanoma patients (23 women, 30 men; median age: 64 years; median tumor thickness: 1.99 mm) with known primary, visible lymph nodes or subcutaneous metastases proven by ultrasound and histopathology during the follow-up. RESULTS: Especially in the axilla, infraclavicular region and groin the metastases were not limited to the anatomic lymph node regions. In 5 patients (9.4%) (4 of them were in stage IV) lymph node metastases were not located in the corresponding lymph node area. 32 patients without former SLNB had a time range between melanoma excision and lymph node metastases of 31 months (median), 21 patients with SLNB had 18 months (p < 0.005). In 11 patients with positive SLNB the time range was 17 months, in 10 patients with negative SLNB 21 months (p < 0.005); in 32 patients with CLND the time range was 31 months and in 21 patients without CLND 18 months (p<0.005). In thinner melanomas lymph node metastases occurred later (p<0.05). CONCLUSIONS: After surgery of cutaneous melanoma, SLNB and CLND the lymphatic drainage can show significant changes which should be considered in clinical and ultrasound follow-up examinations. Especially for high-risk melanoma patients follow-up examinations should be performed at intervals of 3 months in the first years. Patients at stage IV should be examined in all regional lynph node areas clinically and by ultrasound.

Somatic mosaicism of chromosome 7 in a highly proliferating melanocytic congenital naevus in a ring chromosome 7 patient.

Ring chromosome 7 is a rare but well documented chromosomal aberration in man. So far at least 14 cases have been reported in the literature showing a variable but distinct pattern of phenotypic characteristics in affected individuals. Besides others, skin findings as pigmented naevi are especially frequent. Loss of chromosomal material from the terminal chromosome arms in the structurally abnormal ring chromosome 7 as well as somatic mosaicism with loss or gain of chromosome 7 has been suggested to be responsible for the clinical symptoms. We now report another case of a ring chromosome 7 in a 14-year-old boy with multiple remarkable congenital naevi, where we could demonstrate for the first time somatic mosaicism showing significant gain of chromosome 7 within a highly proliferating melanocytic congenital naevus (MCN).

Lymph node metastases in patients with cutaneous melanoma: improvements in diagnosis by signal-enhanced color Doppler sonography.

The purpose of the study was to evaluate whether signal-enhanced color Doppler sonography (CDS) is superior to native CDS in detection of characteristic vascularity patterns that are important for the differentiation between benign and malignant lymphadenopathy in patients with cutaneous melanomas. Twenty-two melanoma patients presenting with 24 structures suspicious for metastases in B-Mode sonography were examined using native and signal-enhanced CDS in a prospective two-center study. Presumptive sonographic diagnoses were compared with results of histopathological and follow-up examinations. Signal-enhanced CDS gave additional information about vascularization of lymph node metastases and reactive lymph nodes, which was indicative for the differential diagnosis in 12 of 24 examinations. For lymph node metastases, signal enhancement improved the visualization of accessory peripheral vessels in four of 10 examinations. Concerning reactive lymph nodes, hilar vessels in part with branching to the lymph node periphery could be better identified after application of the contrast enhancer in eight of 13 examinations. Signal-enhanced CDS is demonstrated as an important additional diagnostic tool for improved differentiation between malignant and reactive lymph nodes and may be of special value in preventing unnecessary lymphadenectomy in small reactive lymph nodes.