Ivo Sazunic

Ultrasound detection and identification of cosmetic fillers in the skin.

Background  While the incidence of cosmetic filler injections is rising world‐wide, neither exact details of the procedure nor the agent used are always reported or remembered by the patients. Thus, although complications are reportedly rare, availability of a precise diagnostic tool to detect cutaneous filler deposits could help clarify the association between the procedure and the underlying pathology.

Activity assessment in morphea using color Doppler ultrasound.

BACKGROUND Morphea (circumcripted cutaneous scleroderma) can be difficult to assess for lesion activity. Because variable-frequency ultrasound with color Doppler provides details of skin morphology and function, it may help in the categorization of morphea. OBJECTIVE We sought to evaluate color Doppler ultrasound as a probing tool for assessing activity in morphea lesions. METHODS Consecutive patients with cutaneous morphea referred by dermatologists were studied with color Doppler ultrasound, and the assessment of lesion activity was compared with histologic findings. Normal skin controls were obtained by performing ultrasound scans of healthy subjects or of unaffected areas of the patients themselves. Measurements included cutaneous layer thickness, relative echogenicity, and blood flow with peak systolic velocity. Ultrasound sensitivity and specificity were determined for each phase of morphea activity and the results correlated with histology. RESULTS Fifty-one patients had a total of 104 morphea lesions. Of the lesions, 20% were active, 22% were atrophic, and 58% were inactive. Five of the patients had the Parry-Romberg syndrome with ipsilateral parotid gland inflammatory involvement, and one had an asymptomatic but sonographically active morphea lesion. Sensitivity and specificity for ultrasound diagnosis were 100% and 98.8%, respectively. The most accurate sonographic signs of lesion activity were increased subcutaneous tissue echogenicity and increased cutaneous blood flow (sensitivity and specificity 100% and 100% for each one). LIMITATIONS Ultrasound cannot define lesions less than 0.1-mm deep. CONCLUSIONS The morphologic and functional data obtained noninvasively and in real time with color Doppler ultrasound provide new insight into the pathogenesis of morphea. The technique represents a useful counterpart to histologic examination for the assessment of lesion activity.

Benign Tumors and Pseudotumors of the Nail A Novel Application of Sonography

Objective. The purpose of this study was to determine the scope of high‐resolution sonography in the detection of benign tumors and pseudotumors of the nail unit. Methods. We performed a retrospective study of the sonographic findings in 103 consecutive patients with benign tumors and pseudotumors of the nail that were medically derived and confirmed histologically. Statistical analysis (Student t test) was performed comparing clinical and sonographic diagnoses. Results. Common benign tumors and pseudotumors of the nail can be detected on sonography, and they present different sonographic morphologic characteristics. According to origin, the lesions were considered ungual in 73% (n = 75) and periungual in 27% (n = 28) of the cases. Sonography showed their nature (solid or cystic), location, and extension as well as regional blood flow. In 35% of the cases, the use of sonography modified the clinical diagnosis, although the detailed anatomic information provided by sonography was useful in the planning of surgery in all cases. The addition of sonography was significant (P < .001) for the diagnosis of subungual exostosis and granulomas in comparison to clinical diagnosis. Conclusions. Sonography is a noninvasive imaging method that can reliably detect common benign tumors and pseudotumors of the nail and provide precise data about their characteristics. This imaging modality can support diagnosis and surgery and can allow a better definition and improvement of the cosmetic outcome of the treatment.

Sonography of Plantar Warts Role in Diagnosis and Treatment

Objective. The purpose of this presentation is to show the sonographic morphologic characteristics of plantar warts and the scope of sonography in the treatment of these lesions. Methods. We retrospectively reviewed 27 sonographic examinations of the plantar region; 17 corresponded to plantar warts diagnosed by dermatologists in which the diagnoses were medically derived from sonographic examinations after failure of their treatments. The remaining group consisted of 10 healthy individuals. Sonograms were compared with standard histologic findings. Results. The sonographic features of normal plantar skin and plantar warts are described, including the shape, echogenicity, pattern of growth, involvement of skin layers, and blood flow in the lesions. Conclusions. Sonography may be considered as reliable support for plantar wart diagnosis and may have a role in the evaluation of plantar wart treatment modalities, allowing monitoring of therapeutic responses, especially in recurrent and difficult cases with persistent symptoms such as pain.

Anatomical Detection of Inflammatory Changes Associated with Plantar Warts by Ultrasound

Background: Plantar warts are common and pain is one of the main symptoms. The anatomical alterations associated with the primary lesion are unclear. Moreover, an adequate separation between the lesion and the surrounding tissue abnormalities could help to better manage this pathology and enable the provision of comprehensive information to physicians and patients. Methods: A color Doppler ultrasound examination was performed on 29 recurrent plantar warts and 10 healthy controls. The morphology and extension of the warts and surrounding soft tissue abnormalities are described. The diagnosis of a plantar wart was correlated with a standard histology in all cases. Statistical analysis was performed by the Student t test. Results: On ultrasound, all warts were recognizable, and sonographic signs of soft tissue inflammation were detected that were associated with the warts: in 79% (23/29) of the cases there was an increase in sublesional arterial blood flow in the dermis, 54% (16/29) had a plantar bursitis, and 52% (15/29) had a focal decrease in subcutaneous echogenicity. No signs of inflammation were seen in the unaffected controls. Conclusion: Ultrasound can provide detailed anatomical data on warts and their inflammatory changes in the surrounding tissues. This noninvasive imaging technique may help to manage difficult cases.

Ultrasound as predictor of histologic subtypes linked to recurrence in basal cell carcinoma of the skin.

Basal cell carcinoma (BCC) recurrences, especially in the facial region, represent a complex cosmetic problem. To date the possibility of predicting recurrence is supported solely by the histologic subtype.

Sonographic Anatomy of the Skin, Appendages, and Adjacent Structures

Recognition of normal sonographic anatomy is of utmost importance when performing imaging examinations. The ultrasound morphology of the skin layers, appendages, and adjacent structures in correlation with the histological findings is provided. Common anatomical variants are also discussed

Topical photodynamic therapy with 5-aminolevulinate for the treatment of tumor-stage mycosis fungoides: a case report

A 70-year-old male patient with generalized tumor-stage mycosis fungoides (MF) presented to our office. He had been treated with psoralen + ultraviolet A, bexarotene, and total-skin electron beam radiation with poor response. He rejected systemic chemotherapy. The most uncomfortable lesions were those involving his face, fingers, buttocks, and calcaneus region (Fig. 1a). Skin biopsy confirmed the diagnosis (Fig. 2a). We offered him topical photodynamic therapy (PDT) with methyl-aminolevulinate (MAL). A 1-mm thick layer of 160 mg/g MAL cream (Metvix ; Photocure ASA, Oslo, Norway) with a 5 mm of margin was applied and covered with an occlusive dressing (Tegaderm ; 3M Health Care, St. Paul, MN, USA) for three hours on his fingers and buttocks, and in the calcaneus region. MAL was then cleaned with physiologic solution 0.9%. Irradiation was done with red light using a Waldmann lamp (PDT 1200 L, incoherent light source lamp) with a wavelength of 570–670 nm, 37 J/cm, and 70 mW/cm. Two to three sessions were done, depending on the lesion, each one separated by two weeks. Complete clinical and histological remission was achieved after treatment (Figs. 1b and 2b). No recurrences after five years of follow-up have been observed in the treated areas. New lesions have appeared in non-treated areas with excellent response to conventional therapies.

Malignant melanoma in Chile: different site distribution between private and state patients

BackgroundThe body site location of primary Malignant Melanoma (MM) has been correlated with prognosis and survival. Ethnic, genetics, sun exposure factors are related to the anatomical distribution of MM. Low and high socioeconomic strata in Chile differ in ethnic, genetic and cultural conditions. The purpose of this study was to analyze the anatomical MM distribution in the Chilean population in both strata searching for differences due to their ethno-genetic-cultural differences. Records of 1148 MM, 575cases from state hospitals (Low Socioeconomic Strata, LSS) and 573 cases from private clinics (High Socioeconomic Strata, HSS) were analyzed by body site.ResultsFemales from LSS showed a higher number of MM in soles, cheeks, and around the eye area. Females from the HSS showed a higher number of MM in dorsal feet and dorsal hands. Males from LSS showed a higher number of MM in soles, around the eye area, and cheeks. However, males from HSS showed a higher number of MM in the trunk, and in the arms. Acral MM was significantly higher in LSS than in the HSS in both sexes. The Chilean population from the HSS and LSS showed differences in the distribution of MM by site. Furthermore, gender differences in the proportion of MM analyzed by anatomical site are observed in both strata.ConclusionsResults show evidence that differential genetics factors, sun exposure, or other environmental or cultural factors of both strata may account for these differences.BACKGROUND The body site location of primary Malignant Melanoma (MM) has been correlated with prognosis and survival. Ethnic, genetics, sun exposure factors are related to the anatomical distribution of MM. Low and high socioeconomic strata in Chile differ in ethnic, genetic and cultural conditions. The purpose of this study was to analyze the anatomical MM distribution in the Chilean population in both strata searching for differences due to their ethno-genetic-cultural differences. Records of 1148 MM, 575 cases from state hospitals (Low Socioeconomic Strata, LSS) and 573 cases from private clinics (High Socioeconomic Strata, HSS) were analyzed by body site. RESULTS Females from LSS showed a higher number of MM in soles, cheeks, and around the eye area. Females from the HSS showed a higher number of MM in dorsal feet and dorsal hands. Males from LSS showed a higher number of MM in soles, around the eye area, and cheeks. However, males from HSS showed a higher number of MM in the trunk, and in the arms. Acral MM was significantly higher in LSS than in the HSS in both sexes. The Chilean population from the HSS and LSS showed differences in the distribution of MM by site. Furthermore, gender differences in the proportion of MM analyzed by anatomical site are observed in both strata. CONCLUSIONS Results show evidence that differential genetics factors, sun exposure, or other environmental or cultural factors of both strata may account for these differences.

Subungual Schwannoma with Clinical, Sonographic, and Histologic Correlation

We show an unusual presentation of a schwannoma that was located in the ungual bed of the left great toe. The clinical, color Doppler ultrasound imaging, and histologic findings are shown to illustrate the case. This type of neurogenic tumor and the ultrasound presurgical imaging support should be considered when dealing with subungual tumors of the foot.