To the editor,
We have read with great interest the article by Koibuchi et al. [1], recently published in your journal. We congratulate the authors for their great effort in describing the sonographic findings related to the superficial lymphovascular invasion of malignant melanoma. They have identified a hypoechoic tubular structure within the subcutaneous tissue with inner tiny vascular signals in color Doppler. It was not compressible with the ultrasound probe during sono-palpation and the authors described it as a dilatated lymphovascular branch of the superficial network due to malignant invasion [1]. Likewise, they have identified a hyperechoic area around the aforementioned tubular structure, interpreted as a metastatic lesion [1].
Herein, we need to mention that the interpretation of the hyperechoic halo surrounding the dilatated lymphovascular elements is skeptic. Indeed, sonographic images reported by the authors simply appear as local edema involving the intercellular matrix of fat lobules in the subcutis (Fig. 1) [2, 3]. The infiltrative “behavior” of the edema in between the adipocytes generates multiple, pathological acoustic interfaces, increasing the echogenicity of the normally hypoechoic fat tissue located in the subcutaneous layer [2, 3]. Actually, in line with our consideration above, Koibuchi et al. stated that the hyperechoic halo completely disappeared after the fine-needle aspiration [1]—making the suspected diagnosis of metastasis quite unlikely.
Fig. 1.
The hyperechoic halo—interpreted as (probable) metastasis by the authors (white arrowheads)—looks more like infiltrative edema of the intercellular matrix of fat lobules (yellow dotted lines) in the subcutaneous layer (subc) i.e. rather than a “solid” lesion. d dermis
In conclusion, we strongly suggest to always use standardized sonographic protocols while examining the superficial tissues [3, 4]. This would definitely avoid unintentional misinterpretation of specific sonographic findings in clinical practice.
Funding
No funding was received.
Declarations
Conflict of interest
The authors have no conflict of interest.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Footnotes
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References
- 1.Koibuchi H, Ishikawa M, Yamamoto S, et al. Spontaneous regression of lymphovascular invasion and metastasis of malignant melanoma: ultrasound findings. J Ultrasound. 2022 doi: 10.1007/s40477-022-00752-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ricci V, Ricci C, Gervasoni F, et al. From physical to ultrasound examination in lymphedema: a novel dynamic approach. J Ultrasound. 2022;25(3):757–763. doi: 10.1007/s40477-021-00633-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ricci V, Ricci C, Gervasoni F, et al. From histo-anatomy to sonography in lymphedema: EURO-MUSCULUS/USPRM approach. Eur J Phys Rehabil Med. 2022;58(1):108–117. doi: 10.23736/S1973-9087.21.06853-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ricci V, Ricci C, Cocco G, et al. From histology to sonography in skin and superficial tissue disorders: EURO-MUSCULUS/USPRM* approach. Pathol Res Pract. 2022;237:154003. doi: 10.1016/j.prp.2022.154003. [DOI] [PubMed] [Google Scholar]