The tail sign and the string sign: a new sonography (US) finding in patients with superficial melanoma metastasis

Transcription

1 The tail sign and the string sign: a new sonography (US) finding in patients with superficial melanoma metastasis Poster No.: C-1088 Congress: ECR 2012 Type: Scientific Exhibit Authors: A. Nunziata, O. Catalano, F. Sandomenico, P. P. Saturnino, A Petrillo ; Ercolano/IT, Naples/IT, Napoli/IT, Caserta/IT Keywords: Diagnostic procedure, Ultrasound, Oncology, Musculoskeletal soft tissue, Metastases DOI: /ecr2012/C-1088 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 26

2 Purpose This exhibit illustrated a new US finding recognizable in patients with superficial metastasis from cutaneous melanoma. The superficial metastases are identified as satellites if these are distant less of 2 cm from the primary melanoma or as in -transit if these are distant more than 2 cm from it (Table 1 on page 4). Table 1: Drawing of locoregional spread of cutaneous melanoma. References: A. Nunziata; Dept. of Radiology, ASL Napoli, Ercolano, ITALY The "tail sign" is the presence of a thin and hypoechoic longitudinal prolongation at one or both poles of melanomatous lesions. We believe that this is due to the dilated, tumour-cells filled lymphatic along which the metastasis has grown. In some case the prolongation connects multiple in-transit lesions and we call this the "string sign" (Table 2 on page 5), (Table 3 on page 6). Page 2 of 26

3 Table 2: Tail sign: Radiologic-pathologic correlation. Primary cutaneous melanoma (blue arrows); dilated and tumour-cells filled lymphatic ducts (red arrows). References: Dept of Radiology 1, National Cancer Institute, Naples/IT Page 3 of 26

4 Table 3: HRUS: those are two example of the tail and string sign that we will show one by one in the next slides. References: Dept of Radiology 1, National Cancer Institute, Naples/IT Images for this section: Page 4 of 26

5 Table 1: Drawing of locoregional spread of cutaneous melanoma. Page 5 of 26

6 Table 2: Tail sign: Radiologic-pathologic correlation. Primary cutaneous melanoma (blue arrows); dilated and tumour-cells filled lymphatic ducts (red arrows). Page 6 of 26

7 Table 3: HRUS: those are two example of the tail and string sign that we will show one by one in the next slides. Page 7 of 26

8 Methods and Materials From a RIS/PACS research we reviewed, by consensus of two radiologists, the highresolutionusimages of 531 consecutive melanoma patients (January 2007-December 2010) during their staging/follow-up. In-transit metastases were present in 89 cases (16.8%), which showed 222 lesions (1-12/patient, mean 3). The tail sign was defined as a small prolongation from one or both lesion's poles (Fig. 1 on page 9), (Fig. 2 on page 10). The string sign was defined as a hypoechoic band connecting two metastases or more (Fig. 3 on page 11), (Fig. 4 on page 12). Fig. 1: HRUS longitudinal view(a,b,c,d): melanoma in-transit metastasis (inguinal region) which shows the tail sign (arrows) the color-doppler study (B) excludes the possibility of a vessel. References: Dept of Radiology 1, National Cancer Institute, Naples/IT Page 8 of 26

9 Fig. 4: HRUS longitudinal view (A,B): trapezoidal image melanoma in-transit metastasis of the axillary region show string sign. References: Dept of Radiology 1, National Cancer Institute, Naples/IT Images for this section: Page 9 of 26

10 Fig. 1: HRUS longitudinal view(a,b,c,d): melanoma in-transit metastasis (inguinal region) which shows the tail sign (arrows) the color-doppler study (B) excludes the possibility of a vessel. Page 10 of 26

11 Fig. 2: HRUS longitudinal view (A,B): melanoma in-transit metastasis (leg) which shows the tail sign (arrows) the CF study (B) exclude the possibility of a vessel. Page 11 of 26

12 Fig. 3: HRUS longitudinal view (A): melanoma in-transit metastasis where it's visible the duct that join the lesion (string sign) (arrow). HRUS longitudinal view (B): melanoma intransit metastasis of the axillary region the US image shows hypoechoic band connecting metastases (string sign) ; CT exams (C) confirms the metastasis. Page 12 of 26

13 Fig. 4: HRUS longitudinal view (A,B): trapezoidal image melanoma in-transit metastasis of the axillary region show string sign. Page 13 of 26

14 Results The tail sign was recognised in 13 lesions (5.9%) and it was identified at one pole in 8 nodules (6,10%) and at both poles in 5 (3,8%). The string sign was found in 4/89 positive patients (4.5%) (Table 4 on page 15 ), (Table 5 on page 16 ). Table 4: On the total of patients with in transit metastasis (89) the tail sign was recognised in 13 lesions (5.9%) and the string sign was found in 4 (4.5%). References: Dept of Radiology 1, National Cancer Institute, Naples/IT Page 14 of 26

15 Table 5: On the total of patients with tail sign (13) it was identified at one pole in 8 (6.1%) nodules and at both poles in 5 (3.8%). References: Dept of Radiology 1, National Cancer Institute, Naples/IT Images for this section: Page 15 of 26

16 Table 4: On the total of patients with in transit metastasis (89) the tail sign was recognised in 13 lesions (5.9%) and the string sign was found in 4 (4.5%). Page 16 of 26

17 Table 5: On the total of patients with tail sign (13) it was identified at one pole in 8 (6.1%) nodules and at both poles in 5 (3.8%). Page 17 of 26

18 Conclusion It is known that in-transit metastases are frequently multiple and aligned longitudinally. However, the possibility to detect with US the dilated lymphatic duct along which these lesions has grown has not been reported yet. The findings we describe are insensitive but very typical, being demonstrative of the melanoma cells spread. Differential diagnosis, although theoretical, includes lymphedema around the nodules, subcutaneous venules, and varicothrombosis, especially when they are near the nodules but it's rare that can be some difficulties in the diagnosis (Fig. 5 on page 18), (Fig. 6 on page 19), (Fig. 7 on page 20). Fig. 11: Cat tail References: Saturnino Pietro Paolo, Naples/IT Images for this section: Page 18 of 26

19 Fig. 5: Differential diagnosis: HRUS longitudinal view (A,B) with the use of extended field of view (EFOV): thrombosis of small saphenous vein the CF confirm the absence of signal flow. HRUS longitudinal view (C) :nodule along the small saphenous vein. Page 19 of 26

20 Fig. 6: HRUS longitudinal view (A) with the use of extended field of view (EFOV): thrombosis of varicose veins ; trapezoidal image (B). Page 20 of 26

21 Fig. 7: HRUS longitudinal view in transit nodule surrounded by edema (calipers). Page 21 of 26

22 References 1. Catalano O, Siani A. Cutaneous melanoma: role of ultrasound in the assessment of locoregional spread. Curr Probl Diagn Radiol 39:30-36, Catalano O, Caracò C, Mozzillo N, Siani A. Locoregional spread of cutaneous melanoma: sonography findings. AJR 194: , Catalano O, Setola SV, Vallone P, Mattace Raso M, Gallipoli D'Errico A. Sonography for locoregional staging and follow-up of cutaneous melanoma. J Ultrasound Med 29: , Catalano O, Sandomenico F, Siani A. Value of the extended field of view modality in the sonographic imaging of cutaneous melanoma: a pictorial essay. Dermatol Surg 36: , Catalano O. Critical analysis of the ultrasonographic criteria for diagnosing lymph node metastasis in patients with cutaneous melanoma: a systematic review. J Ultrasound Med 30: , Solivetti FM, Di Luca Sidozzi A, Pirozzi G, Coscarella G, Brigida R, Eibenshutz L. Sonographic evaluation of clinically occult in-transit and satellite metastases from cutaneous malignant melanoma. Radiol Med 2006; 111: Thompson JF, Hunt JA, Culjak G, Uren RF, Howman-Giles R, Harman CR. Popliteal lymph node metastasis from primary cutaneous melanoma. Eur J Surg Oncol 2000;26: Tregnaghi A, De Candia A, Calderone M, Cellini L, Rossi CR, Talenti E, Blandamura S, Borsato S, Muzzio PC, Rubaltelli L. Ultrasonographic evaluation of superficial lymph node metastases in melanoma. Eur J Radiol 1997;24: Uren RF, Howman-Giles R, Thompson JF, Shaw HM, Roberts JM, Bernard E, McCarthy WH. High-resolution ultrasound to diagnose melanoma metastases in patients with clinically palpable lymph nodes. Australas Radiol 1999;43: Voit C, Schoengen A, Schwürzer-Voit M, Weber L, Ulrich J, Sterry W, Proebstle TM. The role of ultrasound in detection and management of regional disease in melanoma patients. Semin Oncol 2002;29: Zbytek B, Carlson JA Granese J, Ross J, Mihm MC, Slominski A. Current concepts of metastasis in melanoma. Expert Rev Dermatol 2008; 3: Personal Information Antonio Nunziata, Dept of Radiology, P."S. Bellone", ASL Napoli 1 centro, Naples/IT Page 22 of 26

23 Orlando Catalano, Dept of Radiology I, National Cancer Institute "G.Pascale", Naples/IT Fabio Sandomenico, Dept of Radiology I, National Cancer Institute "G.Pascale", Naples/IT Pietro Paolo Saturnino, Radiology Institute, Second University of Naples, Naples/IT Antonella Petrillo, Dept of Radiology I, National Cancer Institute "G.Pascale", Naples/IT Images for this section: Fig. 8: Logo Page 23 of 26

24 Fig. 9: Logo Page 24 of 26

25 Fig. 10: Logo Page 25 of 26

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