We carefully chose the station contralateral to the site of the excised lesion and the sentinel node, to reduce the possibility of contamination from post-surgical interference and the statistical probability of metastases. The melanoma thickness, which we measured for descriptive purposes only according to the Breslow criteria, ranged from 0.7 to 1.3 mm. The following ancillary findings with US are considered to be significant or potentially indicative of a pathology, although they have a low diagnostic value: lymph node diameter greater than 20 mm thickness of the lymph node cortex greater than 2 mm, and an echo-poor central hilus.Ī total of 124 individuals (74 females and 50 males) were included in the study they ranged in age from 12 to 83 years (mean age of 55.3 years and modal age of 55.5 years). Given that the US follow-up of groin lymph nodes consisted of bilateral examination of the stations in the inguinal area – as previewed by the Regional Health Service and for the unlikely occurrence of contralateral metastases - we decided to evaluate, for this study, the opposite side of theoretical lymphatic drainage of excised neoplasia.Īccording to the literature, to be defined as “normal”, a lymph node must be oval in shape, with a long-to-short-axis ratio (L/S ratio or roundness index) of > 2 it must have a regular and homogeneous central echoic hilus, a hypoechoic cortex with a homogeneous structure, with regular and well-defined outlines, without extroflexions, with vascular signals shown by color-power Doppler mainly located centrally and with a regular aspect, and scarce or absent peripheral vascular signals. In light of these considerations, among individuals who had undergone surgery for melanoma, in areas theoretically draining to the groin lymph nodes, we assessed the occurrence of such lymph nodes and their US features (e.g., number, size, and morphologic and architectural characteristics), in order to better identify them. However, when a radiologist defines lymph nodes as “atypical” – even if typical metastatic patterns are not present - clinicians may be prone to perform additional yet unnecessary invasive procedures, such as agobiopsy or even excisional biopsy. These lymph nodes are particularly frequent in the groin area, even in healthy individuals, where they are often involved in acute or chronic micro-infections of the legs, caused by different noxae, such as trauma, micro-wounds, sports activities, incorrect epilation, or diabetes. In the follow-up of patients surgically treated for melanoma, ultrasound (US) examination of the naturally draining lymphatic stations very often reveals lymph nodes that appear as irregular or atypical, without clear aspects of metastases. Based on these results, we can conclude that focusing excessively on such US findings could lead to the inappropriate performance of additional diagnostic tests, with a consequent increase in management costs and a worsening of the quality of life for these patients. Of the 124 patients, who were followed for at least one year, 42 showed these characteristics, and none of these showed any progression to malignancy at follow-up. We found a very high number of patients (42/124) with lymph nodes that did not appear to be fully normal at US examination, particularly those with structural alterations in the hilus and slight loss of physiologic curvature of the outlines, with moderate thickening of the cortex. A second US examination was performed on the same area after at least 12 months. The following parameters of the US performed on the lymph nodes were evaluated: number and size, aspects of the outline, including any extroflexion of the outline and contours morphology, homogeneity and thickness of the cortex and aspects of the hilus, characteristics of the vascularisation of the lymph node at color-power Doppler. The study population consisted of patients who presented consecutively to our facility for a control between 1 January 2009 and 30 July 2010 and who had undergone surgery for a melanoma, at least 6 months earlier, in areas draining to lymph nodes of the groin but choosing – for this study - the opposite side to the natural drainage. We evaluated such lesions among a cohort of patients. Among patients undergoing follow-up after surgery for melanoma, ultrasound (US) very often reveals lymph nodes in groin area, that do not show clear characters of a metastatic lesion yet that have atypical US features, which could result in diagnostic uncertainty.
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