Tag Archives: cancer

Dermatologic Ultrasound: Skin Deep Knowledge

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According to the recent European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound,1 dermatologic ultrasound is the application of ultrasound to the diagnosis of skin and appendages (hair and nails) diseases, as well as their healthy state, and cosmetic alterations.

This application was born as a necessity to answer challenges in dermatology that could not be addressed with superficial exploration methods such as clinical inspection, wood lamp, or dermoscopy, which mainly offer 2D views of the skin. The possibility of adding a third dimension (depth) and even a 4th one (with Doppler or dynamic explorations) with ultrasound makes dermatologic ultrasound a new way to go from guessing what’s happening below the surface to “seeing” what is really happening.

Ultrasound follow-up of intralesional glucantime injection in a cutaneous leishmaniasis. a) Clinical before treatment, b) B-mode before treatment, c) Color Doppler before treatment, d) Clinical after 3 injections, d) B-mode after 3 injections, d) Color Doppler after 3 injections.

During my years of clinical practice incorporating ultrasound in dermatology, I have heard some questions that always seem to arise in meetings. These are some of them:

What are the technical requirements for quality dermatologic ultrasound?

Although equipment with 70 MHz can be helpful to elucidate very concrete aspects of skin pathology, most questions and clinical situations in dermatology can be addressed today with high-quality conventional equipment above 15 MHz with color Doppler.

Apart from high-quality equipment, having a deep knowledge of dermatology, basic ultrasound, and its physical principles is the key to performing appropriate explorations in dermatologic ultrasound.

Which are the main fields of dermatologic ultrasound?

The fields at the forefront of dermatologic ultrasound are skin oncology, inflammatory skin diseases, and cosmetic dermatology.

How can dermatologic ultrasound help us dermatologist in skin oncology?

Skin cancer is the most frequent cancer in the human body. Most malignant skin tumor prognosis and treatment rely on depth and structural invasion, therefore, dermatologic ultrasound is an essential tool compared with MRI or CT in these kinds of evaluations, mainly because of its higher resolution and availability.

Is dermatologic ultrasound helpful in inflammatory skin diseases?

Deep inflammatory skin diseases such as hidradenitis suppurativa and morphea and sclerosing diseases usually do not have clear superficial expression. Dermatologic ultrasound is a key tool for in-depth evaluation of the inflammatory state of these diseases and is a guide for treatment and follow-up.

What are the main applications of dermatologic ultrasound in cosmetic dermatology?

Detection of dermal fillers and the complications and adverse reactions of these medical devices is essential in the management of a responsible cosmetic dermatology practice. Dermatologic ultrasound can also be an excellent tool for skin aging evaluation and anti-aging treatment evaluation.

Who is the AIUM and how can I learn Dermatologic Ultrasound from the AIUM?

The American Institute of Ultrasound in Medicine (AIUM) is the only scientific society that hosts a very active Dermatologic Ultrasound Community, which was funded in 2015 by Ximena Wortsman together with Orlando Catalano (present vice-chair of the community), Fernando Alfageme (present chair of the community and author of this post), and Claudia Gonzalez (secretary).

This community and their members are very active in AIUM meetings, hosting several scientific and didactic sessions, and has also produced some reference papers in dermatologic ultrasound.

The AIUM has hosted several sessions and workshops in AIUM meetings in the last 5 years with the collaboration of the dermatologic ultrasound community, although a need for structured teaching and learning is still necessary for those who are interested in this subspecialty.

Dermatology is an amazing application for ultrasound and it will be key in the near future for high quality, personalized skin medicine to foster the best, responsible care for our patients.


Fernando Alfageme, MD, is a Dermatologist and Chair of the Dermatologic Ultrasound Community (AIUM) as well as Codirector of the Ultrasound Learning Centre (Dermatology) at EFSUMB.

Reference

Alfageme F, Wortsman X, Catalano O, et al. European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound. Ultraschall Med. 2020 May 7. Online ahead of print. doi: 10.1055/a-1161-8872.

Ultrasound-Guided Cancer Imaging: The Future of Targeted Cancer Treatment

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Tumor margins and malignant grade are best defined by vascular imaging modalities such as Doppler flow or contrast enhancement combined with videomicroscopy. The following are image-guided treatment options that can be performed on breast, prostate, liver, and skin cancers.

NEW DOPPLER APPLICATIONS

Blood vessel mapping using the various Doppler modalities is routinely used in both cancer treatment and reconstructive planning. In cancer surgery, it is critical to locate aberrant veins or arterial feeders in the operative site so postoperative blood loss is minimized. Advanced 3D Doppler systems allow for histogram vessel density measurement of neoplastic angiogenesis.

VESSEL DENSITY INDEX

(Fig 1) Baseline neovascularity is a treatment surrogate endpoint and therapy is maintained, increased, or suspended based on quantitative angiogenesis data.

SOLID ORGAN CANCER IMAGING UPDATES

Breast cancer, invading the lower dermis and nipple, discovered with high-resolution probes signifies the tumor has outflanked clinical observation essential for detecting the newly discovered entity of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This capability is also vital for diagnosing the recent epidemic of male breast cancers arising near the mammographically difficult nipple areolar complex, occurring in our 911 First Responders.

For prostate cancer, 4D ultrasound can identify low-grade cancer delimited by the capsule and with low vessel density, and should be followed serially at 6-month intervals.

CONTRAST-ENHANCED ULTRASOUND (CEUS)

In 1990, Dr. Rodolfo Campani developed ultrasound contrast for liver imaging and Drs. Cosgrove (London) and Lassau (Paris) extended the use to breast, skin, and prostate tumors. CEUS is currently used worldwide but is not Food and Drug Administration (FDA)-approved in the United States.

One use for CEUS is microbubble neovascularity, which demonstrates therapeutic response since the Response Evaluation Criteria in Solid Tumors (RECIST) studies noted tumor enlargement during treatment might be related to cell death with cystic degeneration or immune cell infiltration destroying malignant tissue. Doppler ultrasound or CEUS reliably verifies decreased angiogenesis in place of contrast CT or dynamic contrast-enhanced (DCE) MRI. If vascular perfusion ceases, thermal treatments, such as cryotherapy, high-intensity focused ultrasound (HIFU), or laser ablation, should be completed.

Four-dimensional (4D) ultrasound imaging is real-time evaluation of a 3D volume so we can show the patient immediately the depth and the probability of recurrence. Specific echoes in skin cancer generated by nests of keratin are strong indicators of aggression and analyzed volumetrically. Highly suspect areas are checked for locoregional spread and a search is performed for lymphadenopathy so we can determine if the disease is confined and whether further surgical intervention is unlikely at this time. Patients are reassured because they simultaneously see the exam proceed in systematic stages. In serious cases, the patient is forewarned that the operation involves skin grafts and tissue construction.  4D ultrasound permits image-guided biopsy of the most virulent area of the dermal tumor and allows the pathologist to focus on the most suspicious region of the lymph node mass excised from the armpit, neck, or groin. Some laboratories are using postop radiography and sonography for better specimen analysis.

VIDEO DIGITAL MICROSCOPY VS BIOPSY

Fear of complications can deter patients from seeking medical opinion and surgical intervention, so many opt for noninvasive options. Imaging can help to reduce unnecessary biopsies because it can help identify the 1 out of every 33,000 moles that is malignant, while weeding out those that are not.

Once skin cancer is diagnosed, the treatment depends on depth penetration, possibly involving facial nerves, muscles around the eye and nasal bone or ear cartilage. Verified superficial tumors are treated topically or by low dose non-scarring radiation. Many cancers provoke a benign local immune response or coexistent inflammatory reaction that simulates a much larger area of malignancy, and cicatrix accompanies the healing response. 4D imaging combined with optical microscopy (RCM (reflectance confocal microscopy) or OCT (optical coherence tomography)) defines the true border during surgery, sparing healthy tissue, resulting in smaller excisional margins and less scar formation.

 

Do you have any tips on incorporating ultrasound in cancer imaging? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

connect_now_live_digital_graphics_e-newsletter-1

Robert Bard, MD, DABR, FASLMS, currently runs a private consulting practice in New York City. He authored Image Guided Dermatologic Treatments, Image Guided Prostate Cancer Treatment, and DCE-MRI of Prostate Cancer and is a member of multiple leading international imaging societies. Since 1972, Dr. Bard has pioneered digital imaging technologies as alternatives to surgical biopsies for dermatologic and solid organ neoplastic disease.

Medicine, Music, and Moonlighting

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I love my day job as a gynecologic oncologist at Princess Margaret Cancer Centre in Toronto as well as my role as the clinical lead for Royal Victoria Regional Health Centre regional gynecologic cancer program in Barrie, Ontario. My work keeps me very busy as do my three beautiful daughters. With great friends and family, and some of the best support staff any doctor could ask for, I’ve achieved my goal of becoming a successful doctor and surgeon for women with cancer. But I’ve always had another dream tucked away.

Dodge 2I’ve always been musical – in fact at age 3 I started playing the accordion, which I’m pretty sure was bigger than I was! But I put my musical dreams on hold while I pursued a medical career. I learned to play piano, percussion, and brass, and dabbled with songwriting over the years but most of my time was devoted to my medical training at Western University and University of Toronto.

A few years ago a patient in the palliative care ward asked me to play for her. I brought in my piano and surprised her with an original song I’d prepared for her titled, “It’s So Hard to Say Goodbye.” It was an emotional afternoon and afterward she made me promise that I would pursue my love of music professionally. Well, two albums later, here I am working on my third with two very accomplished and talented songwriters, Steve Dorff (whose songs have been sung by legends Barbra Streisand, Celine Dion, and Whitney Houston, to name a few) and Paul Overstreet (who wrote the number-one hit “Forever and Ever, Amen” for Randy Travis).

Many people ask me how I find the time to be a doctor at two hospitals and a professional musician.

Sometimes after a challenging day at the hospital, it can be hard to do anything at all, let alone write and play music. But music never feels like a chore. It calms my spirit and brings me a sense of peace. I find that music has a unique healing power both for me and for people going through tough times, whether struggling with illness or other personal issues. I always say that my goal is to share my music with as many people as possible with the hope that it will bring to them the same sense of passion, peace, and fulfillment it has brought to my own life. Here are a few ways in which music helps to heal both patients and myself.

How Music Helps Patients

  1. Pain relief
    Overall, music does have positive effects on pain management. It can help reduce both the sensation and distress of chronic pain, postoperative pain, and a range of conditions, according to a paper in the Journal of Advanced Nursing.
  2. Immunity boost
    Music can boost the immune function. A comprehensive study on the neurochemistry of music explains that a particular type of music can create a positive and profound emotional experience, which leads to secretion of immune-boosting hormones as well as endorphins. Listening to music, dancing, or singing can also decrease levels of the stress-related hormone cortisol.
  3. Increase energy and fight fatigue
    Many of my patients sometimes suffer from fatigue due to treatment or the postoperative healing process. Losing themselves in music helps reduce physical and emotional stress and can chase negative emotions away. Musical distraction can also help with sleepless nights.

How Music Helps Me

  1. Staying positive
    Music improves my moods and creates a more positive state of mind that helps me through busy days and emotional times.
  2. Mental and physical workout
    Music helps with concentration and staying focused. In addition, playing the piano improves motor coordination and dexterity – very beneficial when I’m at the operating table.
  3. Calm and cool
    The medical field can be very high-stress and emotionally taxing. Going home and playing the piano or writing lyrics really helps me channel this energy in a positive way. And music has been shown to help lower heart rate and blood pressure, which is great for my long-term health.

How does music affect you? What activities help you escape? How do you balance the demands of the job with your personal interests? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jason Dodge, MD, Med, is a surgical oncologist at Princess Margaret Cancer Centre in Toronto. He participated in the AIUM International Consensus Conference on Adnexal Masses in 2014. You can check out his music on his website or on iTunes.