Clinically misinterpreted melanoma metastases can correctly be diagnosed by ultrasound-guided fine needle aspiration cytology.

Ultrasound-guided fine needle aspiration cytology (US-guided FNAC) of regional nodal basins is increasingly incorporated into the national follow-up schemes of high risk melanoma patients. In this paper we describe an additional added value of US-guided FNAC in the detection and verification of subcutaneous/in-transit metastases. A patient presented with a long lasting, smooth, movable node, close to the scar of the primary melanoma, mimicking a lipoma in every clinical follow-up. Ultrasound at once suspected a metastasis. FNAC was performed within one day of sampling in an outpatient setting, without side effects. A hypothesis of an auto-vaccination in this case could not be proven by examining the T-cell response. Despite the clinically benign aspect of this metastasis, US-guided FNAC can provide diagnosis within 1 day. FNAC is a rapid, cost-effective method, free of complications, of great value in the diagnosis of putative metastases.

Ultrasound morphology criteria predict metastatic disease of the sentinel nodes in patients with melanoma.

PURPOSE We have shown that ultrasound (US) -guided fine needle aspiration cytology (FNAC) can accurately identify the sentinel node (SN). Moreover, US-guided FNAC before the surgical SN procedure could identify up to 65% of all SN metastases. Herein we analyzed in detail the different US morphologic patterns of SN metastases. PATIENTS AND METHODS From July 2001 to December 2007, a total of 650 patients with melanoma scheduled for sentinel lymph node dissection were examined. We present the first 400 with sufficient follow-up (mean 40, median 39 months). Several morphologic characteristics were scored. In case of suspicious/clearly malignant US patterns a FNAC was performed. The final histology was considered the gold standard. Results Median Breslow was 1.8 mm. The sensitivity and positive predictive value of the most important factors were: peripheral perfusion (PP) present (77% and 52%, respectively), loss of central echoes (LCE; 60% and 65% respectively), and balloon shape (BS; 30% and 96% respectively). Together these factors have a sensitivity of 82% and PPV of 52% (P < .001). PP identified more patients with lower volume disease. PP and combined BS and LCE were independent prognostic factors for survival (hazard ratio, 2.19; P < .015; and hazard ratio, 5.50; P < .001, respectively). CONCLUSION Preoperative US and FNAC can identify 65% of SN metastases and thus reduce the need for surgical SN procedures. Peripheral perfusion is an early sign of involvement and of crucial importance to achieve a high identification rate. Balloon shape and loss of central echoes are late signs of metastases. We recommend US evaluation to identify those patients, who can directly proceed to a complete lymph node dissection after a positive US-guided FNAC of the SN.

The evaluation of psoriasis therapy with biologics leads to a revision of the current view of the pathogenesis of this disorder.

Psoriasis is a common chronic, recurring skin disease that is characterised by typical macroscopic and microscopic skin alterations. It is widely accepted that the immune system plays an important role in the pathogenesis of this disorder. Since the early 1990s, the dominant role of a subpopulation of T cells, so-called T1 cells, and their prominent cytokine IFN-gamma has been assumed in the pathogenesis of psoriasis. Surprisingly, the comparison of the therapeutic success of treatments with recombinant proteins directed against defined immunological structures shows that those that directly affect T cells (alefacept, efalizumab, Hu-max-CD4, OKTcdr4a) were clearly less effective than those targeting TNF-alpha (etanercept, adalimumab, infliximab). For this reason, the authors critically re-evaluated the view of psoriasis pathogenesis and postulate that in the majority of patients the T1 cells do not play a dominant role in the clinical, visible stage of this disease.