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Ultrasound Can Identify Skin and Subcutaneous Masses

June 19, 2014

Ultrasound Can Identify Skin and Subcutaneous Masses

  1. Keith R. Barron, MD and
  2. Allan S. Brett, MD

In experienced hands, ultrasound distinguished quite accurately between benign and malignant masses.

  1. Keith R. Barron, MD and
  2. Allan S. Brett, MD

Clinicians often refer patients with skin or subcutaneous masses for ultrasound evaluation, but little is known about its diagnostic accuracy. In this retrospective study from Hong Kong, researchers reviewed 714 ultrasound examinations of superficial soft-tissue tumors that were performed by experienced musculoskeletal radiologists.

In 247 cases for which biopsy results were available, initial ultrasound diagnoses were accurate in 77% of cases. The most common pathologic diagnoses were lipoma (43%), vascular malformation (12%), epidermoid cyst (12%), and nerve sheath tumor (6%). Accuracy of initial ultrasound readings was particularly high for lipoma (95%) and epidermoid cyst (87%). Among 11 patients with confirmed malignancies, radiologists identified 10 masses as malignant; no benign mass was mistakenly identified as malignant on ultrasound.

For the 467 cases without histologic correlation, 8 were considered malignant on ultrasound; clinical follow-up supported malignancy in 5 of these. The remaining 459 masses were considered benign on ultrasound, and long-term follow-up supported benignity in all of them. Pooling all 714 cases, the sensitivity and specificity of ultrasound for malignancy was 94.1% and 99.7%, respectively.

Comment

These results show that ultrasound can differentiate between benign and malignant superficial soft-tissue masses with high accuracy and can distinguish among the most common benign entities with moderate accuracy. Whether less-experienced radiologists can achieve similar accuracy is unclear; indeed, lower accuracy has been documented in several previous studies. Unfortunately, this study doesn't address when imaging for superficial soft-tissue masses is necessary (i.e., we often can identify lipomas or epidermoid cysts confidently on physical examination, without imaging) or how often ultrasound changes outcomes.

Dr. Barron is a Chief Resident in internal medicine at the University of South Carolina in Columbia.

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

Citation(s):

Reader Comments (3)

Fernando Alfageme, MD, PhD Physician, Dermatology, Skin Ultrasound Unit. Dermatology Department Hospital Puerta de Hierro (Madrid) SPAIN

As Dr Wortsmann says in her comment, Ultrasound of skin, really accurate in cysts and lipomas, has a further horizon, that merges with the clinical experience of the operator. As Dermatologists ultrasound has provided us a copernican twist regarding approach to deep skin diseases both tumoral and inflammatory . The assessment of clinical and subclinical inflammation is a guiding tool in the treatment of inflammatory diseases as hidradenitis, lupus and panniculitides. Even fields like trichology (hair diseases) ultrasound provides excellent information about tumoral and inflammatory diseases as recently reported by Dr Wortsmann.

Ximena Wortsman Physician, Radiology, Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, University of Chile

We read with great interest Barron K et al comment on Hung EHY et al article (1) and we agree on the great support of ultrasound for studying skin and soft tissue lesions. Particularly, the usage of ultrasound in dermatology is growingly reported in literature and their common usages include benign and malignant tumors, vascular anomalies, inflammatory diseases, cosmetic complications, nail and scalp pathology (2,3). In our experience the management is commonly modified with the addition of ultrasound in frequent dermatologic conditions. Moreover, the addition of ultrasound to the clinical examination can improve the correctness of dermatologic diagnoses from 73 to 97% (4). For example epidermal cysts are commonly mistaken for pilomatrixomas, and the clinical diagnostic rate reported for pilomatrixomas is as low as 56% (5) which is almost the same probability of throwing a coin in the air; on the other hand, ultrasound can significantly diagnose pilomatrixomas (6).The correlation of depth between histology and ultrasound in basal cell carcinoma, the most common malignant tumor in human beings is reported as very good which can influence the size of the incision and the type of surgery (7). On acne, one of the most common dermatologic diseases, the failure to treatment is reported in as high as 52% (8) and the addition of ultrasound can reveal critical subclinical information such as unsuspected fistulas that may modify the staging of the disease (9). In Hidradenitis suppurativa, a devastating disease that commonly affect the axillae and groin regions the addition of ultrasound has been reported to produce a change in management in 82 % of patients (10). Ultrasound may also be used for detecting and identifying cosmetic fillers which can be very useful in cases with complications that may mimic another dermatologic entities (11,12). We may follow this analysis with numerous examples of the usage of sonography such as the early diagnosis of melanoma metastasis, detection of activity in morphea ad nail tumors, etc (1,2). Thus, the role of ultrasound in the study of the soft tissues seem to go further than the simply use for diagnosing lipomas or epidermal cysts; we believe that this is a technique that provides a potent non invasive window into the skin and soft tissues. It has well known technical requirements as a multichanneled ultrasound machine and high frequency probes as well as reported limitations (2,4). As regards the experience of the radiologists, we believe that all medical techniques require the training of the operator, therefore more motivation on training in this field of imaging is certainly needed. Lastly, considering that we are living in the 21 century, with all this technology worldwide available and the high demand of patients for good medical and cosmetic results, the clinical work on skin and subcutaneous tissue, under blinded basis ( non-image guided) seems to be insufficient and limited.
1- Hung EHY et al. Ultrasound of musculoskeletal soft-tissue tumors superficial to the investing fascia. AJR Am J Roentgenol 2014 Jun; 202:W532. (http://dx.doi.org/10.2214/AJR.13.11457)

2- Wortsman X. Ultrasound in Dermatology: Why, How and When?Seminars in Ultrasound CT and MRI 2013; 34:177-195
3- Alfageme Roldán F.Ultrasound Skin Imaging.Actas Dermosifiliogr. 2014 May 13. pii: S0001-7310(14)00204-X. doi: 10.1016/j.ad.2013.11.015.
4- Wortsman X, Wortsman J,Clinical usefulness of variable frequency ultrasound in localized lesions of the skin. J Am AcadDermatol 2010; 62 : 247-256
5- Roche NA, Monstrey SJ, Matton GE. Pilomatricoma in children: common but often misdiagnosed. Acta Chir Belg. 2010;110:250-254.
6- Choo HJ, Lee SJ, Lee YH, Lee JH, Oh M, Kim MH, Lee EJ, Song JW, Kim SJ, Kim DW.Pilomatricomas: the diagnostic value of ultrasound.Skeletal Radiol. 2010 Mar;39(3):243-50
7- Bobadilla F, Wortsman X, Muñoz C, Segovia L, Espinoza M, Jemec GB. Pre-surgical high resolution ultrasound of facial basal cell carcinoma: correlation with histology. Cancer Imaging. 2008 ;8:163-72.
8- Quéreux G, Volteau C, N'Guyen JM, Dréno B.Prospective study of risk factors of relapse after treatment of acne with oral isotretinoin.Dermatology. 2006;212(2):168-76
9- Wortsman X, Claveria P, Valenzuela F, Molina MT, Wortsman J. Sonography of Acne Vulgaris . J Ultrasound Med 2014; 33: 93-102
10- Wortsman X, Moreno C, Soto R, Arellano J, Pezo C, Wortsman J.Ultrasound in-depth characterization and staging of hidradenitis suppurativa.Dermatol Surg. 2013 Dec;39(12):1835-42.
11- Young SR, Bolton PA, Downie J.Use of high-frequency ultrasound in the assessment of injectable dermal fillers.Skin Res Technol. 2008 Aug;14(3):320-3.
12- Wortsman X, Wortsman J, Orlandi C, Cardenas G, Sazunic I ,Jemec GBE. Ultrasound detection and identification of cosmetic fillers in the skin.J Eur Acad Dermatol Venereol. 2012;26:292-301.

Jacob Dijkstra, M.D. Physician, Dermatology, Cleveland Clinic

US is very helpful to identify deeper nodules as benign nor malignant lymph nodes.

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