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Ultrasound diagnosis of an atypical axillary lesion Christiane A. Voita, Alexander C.J. van Akkooic, Alexander M.M. Eggermontd and Andrea Tüttenbergb We report on the case of a 41-year-old man with a recently diagnosed amelanotic ulcerated melanoma, with a Breslow thickness of 3.5 mm and Clark level IV. He had a pre-existing mass in the axilla, which had grown in parallel to the developing tumor. A large regional lymph node was clinically suspected. Ultrasound (US) examination of the axilla showed a large benign lipoma but also a very atypical peripheral perfusion. At the same time, a sentinel node showed a peripheral perfusion on US. Fine-needle aspiration cytology was performed of the different lesions and showed a melanoma metastasis in the sentinel node. Thereafter, a lymph node dissection was performed. The lipoma was seen in histopathology and even the peripheral perfusion was confirmed. US and US-guided fine-needle aspiration cytology can be easily applied in the diagnosis of lymph node metastases in melanoma patients and can help

Case A 41-year-old male melanoma patient was first diagnosed with a cutaneous amelanotic melanoma, right elbow, in July 2012. The patient was referred to our hospital for wide local re-excision plus sentinel node biopsy. The tumor thickness of the primary was 3.5 mm with Clark level IV and showed ulceration. From the patient’s history and clinical documentation, a huge axillary swelling was known. The patient claimed that the axillary tumor had been developing in parallel to the bleeding of the pre-existing mole on his right elbow. Ultrasound (US) of the abdomen showed no pathologic findings. In addition, chest radiography and computed tomography did not show any evidence of disease. Because of the clinical appearance and the huge palpable lesion at physical examination, a huge axillary regional lymph node involvement was suspected. The lesion was not well defined, not really smooth, and not mobile. Therefore, the sentinel node biopsy had already been cancelled. The patient was sent to the US unit to check for additional (distant) regional lymph node involvement and to further clarify the axillary swelling.

determine a benign or a malignant involvement. Melanoma Res 24:517–521 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Melanoma Research 2014, 24:517–521 Keywords: cytology, fine-needle aspiration cytology, metastatic, sentinel node, ultrasound a

Department of Dermatology, Charité, Humboldt University of Berlin, Berlin, Department of Dermatology, University of Mainz, Mainz, Germany, cDepartment of Surgical Oncology, Erasmus University Medical Center, Daniel den Hoed Cancer Center, Rotterdam, The Netherlands and dInstitute Gustave Roussy Cancer Center, Villejuif, Paris Sud, France b

Correspondence to Christiane A. Voit, MD, PhD, Department of Dermatology, Charité, Humboldt University of Berlin, Charitéplatz 1, 10117 Berlin, Germany Tel: + 49 30 450 618007; fax: + 49 9491 952616; e-mail: [email protected] Received 25 July 2013 Accepted 23 May 2014

lymph node scintigraphy and the scheduled sentinel lymph node biopsy [3–5]. Regional US-guided fineneedle aspiration cytology (FNAC) of lymph nodes could significantly reduce the number of unnecessary surgical sentinel node procedures [6,7]. Thus, patients could directly proceed to a therapeutic completion lymph node dissection in case the sentinel node had turned out to be cytologically involved after US-FNAC. In this case, we performed an US examination of the lymph nodes in both axillae and in-transit distance. The patient’s lymph nodes of the contralateral axillary basin and the in-transit distance yielded no suspicious findings during the US examination. The ipsilateral right axillary basin needed a change in the settings toward deeper depths and lower MHz numbers for a thorough examination. Using only the B-mode, a round echo-poor lesion could be observed in the depth of the axilla. It showed a regular stripe pattern, as is normal for lipomas (Fig. 1). However, it showed an unusual and very atypical peripheral perfusion (Fig. 1). Considering the patient’s history and similarly the rapid growth which the patient had reported, an FNAC of the lesion with a deep fine needle was performed.

Ultrasound examination Examination of the patient’s regional lymph nodes as well as the in-transit distance by US at the time of the diagnosis of a primary melanoma and during regular follow-up is part of the regular staging procedures in Germany and the Netherlands [1,2]. Recent developments have shown the benefit of US examinations of the sentinel nodes within the short time period between 0960-8931 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Moreover, on top of the huge lesion, an oval lesion with central echoes could be observed. This second, smaller lesion primarily resembled a normal reactively enlarged lymph node. However, it showed an asymmetrical echopoor broadening of the parenchyma, which was almost echo-free in B-mode (Fig. 2). The Solbiati index, which measures the quotient of the longitudinal and transversal DOI: 10.1097/CMR.0000000000000105

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Fig. 1

Sonographic aspect of the lipoma in the B-mode and with the power mode showing unusual peripheral perfusion.

Fig. 2

Broadening of the parenchyma of the sentinel node.

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Ultrasound diagnosis of an atypical axillary lesion Voit et al. 519

diameter of the lesion, was above 2, as is normal for ovalshaped lesions. Within the broadened parenchyma, an echo-free island seemed to have caused the broadening. Using a very sensitive pulse repetition frequency and the power mode to depict the smallest vessels, a peripheral

perfusion was observed in exactly this echo-poor island within the broadened parenchyma. As this could be a hint of an early involvement of the sentinel node according to the Berlin criteria [8], an FNAC was also performed in this lesion (Fig. 3a and b).

Fig. 3

(a) Sonographic picture of the echo-poor lesion within the lymph node in the B-mode and image, (b) in power mode.

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Fig. 4

In terms of laboratory parameters, the tumor marker S-100 (0.13) was slightly elevated (normal < 0.105) and lactate dehydrogenase was within the normal range (199 U/l).

Histopathology The lipoma was confirmed by histopathology. Remarkably, even without knowledge of the US report, the vascularization located on top of the lesion and surrounding the lesion had been described in the histopathology report as extraordinary. Of the 17 excised lymph nodes of the lymph node dissection, all except one seemed macroscopically benign (1/17). One showed an impressive histiocytosis of the sinus and underwent several serial cuttings. Surprisingly, no tumor cells could be found in histopathology.

Discussion Fortunately, the clinicians’ suspicion of an involved huge axillary conglomerate could not be confirmed by the results of US and US-FNAC. This would have meant a huge tumor burden, an AJCC stage IIIB, and a high probability of further metastases during the course of disease. After confirmation of US-guided FNAC, the patient could now be classified as AJCC stage IIIA and can benefit well, for example, by pegylated interferon-α therapy in an adjuvant setting and has a definitely lower probability of further dissemination [9].

Overview (a) and × 40 magnification (b) of cytology showing singular large melanoma cells from ultrasound-guided fine-needle aspiration cytology of the in-vivo sentinel node.

Ultrasound-guided fine-needle aspiration cytology The huge lesion showed all the cytological features of a lipoma. The smaller lesion showed lymphatic cells. However, some typical large cells with basophile cytoplasm and granular chromatin of the nucleus with some inclusions could be found between the normal cellular setting of a lymph node (Fig. 4a and b). The diagnosis of a sentinel node metastasis of a malignant melanoma, epithelial subtype, could be verified within hours. After having been informed about a huge lipoma and an involved sentinel node, the surgeons replanned the surgical procedure thoroughly and then performed extirpation of the lipoma together with completion lymph node dissection of the right axilla.

Surprisingly, the tumor cells aspirated by FNAC could not be confirmed in histopathology. First, an error in the interpretation of the cytology should be discussed. However, a second experienced reference center confirmed the malignant melanoma cells. The other possibility would be an inadequate yield of harvested lymph nodes in the lymph node dissection, so that the punctured lymph node would be left behind. The easiest recommendation for these type of situations is a close follow-up of the lymph node basin by US as growing lymph node metastases cannot be overlooked by US. This seems unlikely in this case as the pathologist did receive a total of 17 lymph nodes, indicating a sufficiently extensive lymph node dissection. The third option is that the cells could be so few that they are not even visible in immune histopathology. Then, the lesion would be expected to be located in a subscapular location according to the Dewar criteria [10] and the diameter of the lesion would indicate minimal sentinel node tumor burden according to the Rotterdam criteria as published [11]. This option seems very valid as the 17 lymph nodes from a lymph node dissection are only examined by bivalving and hematoxylin and eosin stains compared with extensive serial sectioning of a single sentinel node. A fourth, but very unlikely possibility would be that during fine-needle aspiration, all malignant cells may have been aspirated.

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For sentinel node status, it means in the case of such a micronest, an estimated 5-year overall survival rate in the range between 90 and 93%, similar to that of patients with a negative sentinel node [1]. Using the primary tumor data in the nomogram of the Sloan Kettering Cancer Center [12], to determine the risk of sentinel node involvement, the calculated risk was found to be 39% in the present case, implying approximately double the risk compared with the a-priori risk. Assuming a larger tumor nest within the sentinel node and integrating the parameters of the primary such as ulceration and tumor thickness, the calculated 5-year overall survival would decrease to 57% using the calculation of the DeCOG (http://ado-homepage.de), or would be as good as 70% considering that the final histopathology was completely negative. The present report is a simple example of how easily the Berlin morphology criteria described and published for melanoma lymph node involvement can be applied and, moreover, how US-guided FNAC can exclude for errors in an instant.

Acknowledgements Conflicts of interest

There are no conflicts of interest.

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Ultrasound diagnosis of an atypical axillary lesion.

We report on the case of a 41-year-old man with a recently diagnosed amelanotic ulcerated melanoma, with a Breslow thickness of 3.5 mm and Clark level...
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