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3 Other Imaging Techniques forSkin
dc
51
Fig. 3.10 MRI of soft tissue tumor (lipoma). Male,
64years of age. (a)An oval lesion can be seen in the subcutaneous tissue of right shoulder joint (size:
21.5×17.2mm). It is regular and well-dened. The surrounding fat space is clear. And the lesion shows hyperin-
tense signal on T1WI.(b) The lesion shows hyperintense
signal on T2WI.(c) The lesion shows hypointense signal
on T2WI-FS. (d) Enhanced MR imaging shows no
enhancement of the lesion. Lesions are indicated by
arrows
52
Resolution (log)
Depth of penetration (log)
Fig. 3.11 Resolution
and imaging depth of
various skin imaging
technologies
10cm
10mm
1mm
100mm
10mm
1mm
CLSM
Ultrasound
biomicroscopy
OCT
Low-frequency
ultrasound
High-frequency
ultrasound
A.-Q. Zhu et al.
Isotope
imaging
CT, MRI
0
1 mm 1cm 10 cm
Table 3.1 Principles and characteristics of common skin imaging technologies
Dermoscopy CLSM OCT Ultrasound
Imaging
technologies
Imaging
Optical Optical Optical Acoustic
principles
Imaging depth 0mm
Transverse
< 10μm 5μm 5~15μm 40μm~1mm
0~350μm
0~2mm 1mm~50mm
resolution
Imaging
direction
Imaging layer Epidermal
Transversal
direction
surface
Transversal
Longitudinal direction Longitudinal direction
direction
Epidermis Epidermis + supercial
dermis
Schematic
diagram
Epidermis + dermis +
subcutaneous tissue
Suggested Reading
1. Yelamos O, Braun RP, Liopyris K, etal. Usefulness
2. Reiter O, Mimouni I, Dusza S, et al. Dermoscopic
of dermoscopy to improve the clinical and histopathologic diagnosis of skin cancers [J]. J Am Acad
Dermatol. 2019;80(2):365–77.
features of basal cell carcinoma and its subtypes:
a systematic review [J]. J Am Acad Dermatol.
2021;85(3):653–64.
3. Carducci M, Bozzetti M, De Marco G, etal. Usefulness
of margin detection by digital dermoscopy in the tradi-
tional surgical excision of basal cell carcinomas of the
head and neck including inltrative/morpheaform type
[J]. J Dermatol. 2012;39(4):326–30.
4. Carducci M, Bozzetti M, Foscolo AM, etal. Margin
detection using digital dermatoscopy improves the
3 Other Imaging Techniques forSkin
53
performance of traditional surgical excision of basal
cell carcinomas of the head and neck [J]. Dermatol
Surg. 2011;37(2):280–5.
5. MacFarlane D, Shah K, Wysong A, et al. The role
of imaging in the management of patients with
nonmelanoma skin cancer: diagnostic modalities and applications [J]. J Am Acad Dermatol.
2017;76(4):579–88.
6. Kawaguchi M, Kato H, Matsuo M. CT and
MRI features of scalp lesions [J]. Radiol Med.
2019;124(10):1049–61.
7. Koustenis A Jr, Harris A, Gross J, et al. Optical
coherence tomography angiography: an overview
of the technology and an assessment of applications for clinical research [J]. Br J Ophthalmol.
2017;101(1):16–20.
Terminology, Image
Interpretation, andArtifacts
forSkin Ultrasound
Hui-XiongXu, Le-HangGuo, An-QiZhu,
Dan- DanShan, andQiaoWang
4
4.1 Terminology andImage
Interpretation
Visual appearance refers to the spatial location
and appearance characteristics of the lesion on
the body surface under the naked eyes. The
above information is signicant for skin disease
diagnosis.
For example, the perineum is a characteristic
site for extramammary Paget’s disease. The glans
is a predisposed site for diseases such as condyloma acuminatum and squamous cell carcinoma.
The face and dorsum of the hands are predisposed sites for diseases such as basal cell carci-
H.-X. Xu (*) · Q. Wang
Department of Medical Ultrasound, Shanghai Skin
Disease Hospital, Ultrasound Research and Education
Institute, School of Medicine, Tongji University,
Shanghai, China
Department of Medical Ultrasound, Shanghai Tenth
People’s Hospital, Ultrasound Research and
Education Institute, School of Medicine, Tongji
University, Shanghai, China
L.-H. Guo
Department of Medical Ultrasound, Shanghai Skin
Disease Hospital, Ultrasound Research and Education
Institute, School of Medicine, Tongji University,
Shanghai, China
A.-Q. Zhu · D.-D. Shan
Department of Medical Ultrasound, Shanghai Tenth
People’s Hospital, Ultrasound Research and
Education Institute, School of Medicine, Tongji
University, Shanghai, China
noma and solar keratosis. Lesions located in
these sites should be considered for associated
highly prevalent diseases rstly.
In addition, if there are appearance changes,
such as wound surface, ulceration, and erythema,
it means that the lesion involves epidermis. The
transducer with the higher frequency is preferred
to display the surface information during the
examination. If there are no appearance changes,
it means that the lesion is deeply located and may
not involve the dermis and epidermis, then a
lower frequency transducer is usually used to
observe the lesion.
4.1.1 Gray-Scale Ultrasound
4.1.1.1 Ultrasound Features
Echogenicity
Echogenicity is the basic parameter to be
described during ultrasound examination of the
lesion and can reect the property of the lesion to
some extent. According to the literatures, during
the skin ultrasound examination, echogenicity is
divided into anechogenicity, hypoechogenicity,
isoechogenicity, hyperechogenicity, and high
echogenicity (Fig.4.1).
Anechogenicity is more common in homogeneous uid, and typical simple cysts are generally anechogenic, such as hepatic cysts and renal
cysts. But the ultrasound ndings of epidermoid
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
H. Xu et al. (eds.), Diagnostic Ultrasound in Dermatology,
https://doi.org/10.1007/978-981-16-7345-0_4
55
56
H.-X. Xu et al.
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c d
e
Fig. 4.1 Lesions with different echogenicity.
(a) Isoechogenic lesion (subcutaneous lipoma).
(b)Hypoechogenic lesion (cutaneous squamous cell carcinoma). (c) Hyperechogenic lesion (subcutaneous
cysts are different from those of typical anechogenic cysts, which shows different echogenicity
because they are often lled with viscous caseous
contents.
Hypoechogenicity can be seen in the adipose
tissue. Isoechogenicity is similar to echogenicity of
liver and spleen parenchyma. Hyperechogenicity
can be seen in subcutaneous lipomas. High echo-
lipoma). (d) High echogenic lesion (calcinosis cutis).
(e)Anechogenic lesion (mucous cyst). Lesions are indicated by arrows
genicity can be seen in abnormal keratinization on
the surface of lesions, often with posterior acoustic
shadowing.
Layers ofInvolvement
The severity of skin disease is highly correlated
with the layers of involvement, and breaking
through the layer of primary disease means dis-
4 Terminology, Image Interpretation, andArtifacts forSkin Ultrasound
57
a
c
Fig. 4.2 Schematic diagram of lesion involvement layers
(Paget’s disease). (a) Gray-scale ultrasound shows the
bottom (yellow dotted line) of the lesion (arrows) reaches
the epidermal/dermal junction (upper red dotted line)
(Frequency: 50 MHz). (b) Gray-scale ultrasound shows
the bottom (yellow dotted line) of the lesion (arrows)
involves the dermis and is located between the junctions
of epidermis/dermis (upper red dotted line) and the der-
b
mis/subcutaneous tissue (lower red dotted line)
(Frequency: 50 MHz). (c) Gray-scale ultrasound shows
the bottom (yellow dotted line) of the lesion (arrows)
breaks through the junction of dermis/subcutaneous tissue
(lower red dotted line) and reaches the subcutaneous tissue layer (Frequency: 50MHz) [Image cited from Chen
ST etal., J Ultrasound Med, 2019, 38(12): 3229–3237]
ease progression. Assessing the layers of involvement of skin disease and the relationship between
the lesion and the two key demarcations (i.e.,
junctions of epidermis/dermis and dermis/subcutaneous tissue) is important (Fig.4.2).
When describing lesions, it is important to
point out the layer where the lesion is located,
which layers are involved, and which demarcation
lines are broken through. When the boundary of
the lesion is ill-dened, it is impossible to determine whether it breaks through a certain demarcation line. The bottom of the lesion to “reach” or
“touch” a demarcation line should be described,
which will give clinicians sufcient alert.
Surface
The boundary of the lesion is mainly observed
through two sides, which are the surface and the
bottom.
Surface morphology is usually based on the
horizontal plane of the surrounding normal skin as
a reference and is divided into four morphologies:
elevated, at, depressed, and wrinkled (Fig.4.3).
Bottom
The bottom is referenced by the natural morphology and the boundary of the lesion. It may be illdened or well-dened, reecting the degree of
involvement of the lesion to deep tissues.
The bottom can be divided into regular and
irregular patterns, and the regular bottom appears
at and convex (deep direction) (Fig.4.4).
Stratum Corneum
The outermost layer of the epidermis is the stratum corneum. Under physiological conditions,
the stratum corneum appears as a continuous,
smooth, and ne linear hyperechoic band on
58
H.-X. Xu et al.
a
c
Fig. 4.3 Surface morphology. (a) Lesion with elevated
surface (basal cell carcinoma). (b)Lesion with depressed
surface (dermatobroma). (c) Lesion with at surface
d
b
(basal cell carcinoma). (d)Lesion with wrinkled surface
(Bowen’s disease). Lesions are indicated by arrows
high-frequency ultrasound without posterior
acoustic shadowing.
When abnormal keratinization including
hyperkeratosis or parakeratosis occurs, the above
hyperechoic band can become thicker, and the
surface turns into irregular shape such as roughness or wrinkle. Various degrees of posterior
acoustic shadowing induced by hyperechoic band
will seriously obstruct the display of deep structure of the lesion and color Doppler ow signals.
Hyperkeratosis or parakeratosis are features of
many skin lesions, which can provide important
information for disease diagnosis. Therefore, it is
not recommended to remove abnormal keratinization in order to rule out posterior acoustic shadowing, otherwise it will lead to changes in the
original morphology of the lesion and cause additional damage.
At this point, the internal information of the
lesion can be observed from the edge of the lesion
or an “ultrasound transmission window” in the
stratum corneum space.
On the other hand, the disappearance of linear
hyperechoic band is observed on the surface in
some lesions, which means the local loss of stratum corneum. It usually appears in uncured
wounds or in the postepidermectomy.
It should be pointed out that in some cases,
hyperechogenicity thickening with posterior
acoustic shadowing does not mean hyperkeratosis or parakeratosis, such as scabs, hair, scars, or
air-containing spaces of skin wrinkle. In this
condition, the ultrasound ndings are similar to
pathological keratosis, which needs to be differentiated in combination with visual appearance
(Fig.4.5).
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4 Terminology, Image Interpretation, andArtifacts forSkin Ultrasound
59
a
b
e
Fig. 4.4 Bottom morphology. (a) Lesion with convex
bottom (basal cell carcinoma). (b)Lesion with at bottom (Bowen’s disease). (c)Lesion with irregular bottom
(cutaneous squamous cell carcinoma). (d) Lesion with
Shape
Hemispherical, oval, crawling, and irregular
shapes are common.
Hemispherical shape refers specically to the
lesion with a at bottom and elevated surface,
which is common in diseases such as seborrheic
keratosis and epidermal nevus (Fig.4.6a).
Oval shape is common in benign lesions of
ill- dened bottom (cutaneous squamous cell carcinoma).
(e) Lesion with well-dened bottom (basal cell
carcinoma)
Crawling shape is usually conned to the
epidermis, manifested as a narrow hypoechogenic band parallel to the body surface. The longitudinal section is signicantly smaller than
the cross section. The shape is unique for skin
diseases, which is common in psoriasis, Bowen’s
disease, and extramammary Paget’s disease
(Fig.4.6c).
dermal or subcutaneous tissue (Fig.4.6b).
60
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H.-X. Xu et al.
a
c
Fig. 4.5 Various shapes of stratum corneum. (a)Normal
stratum corneum (normal skin). (b) Thickened stratum
corneum (Bowen’s disease). (c)Absent stratum corneum
b
(cutaneous squamous cell carcinoma). Arrows point to the
location of stratum corneum
Fig. 4.6 Shapes of lesions. (a)Lesion with hemispherical
shape (intradermal nevus). (b) Lesion with oval shape
(cutaneous squamous cell carcinoma). (c) Lesion with
crawling shape (seborrheic keratosis). (d) Lesion with
irregular shape (cutaneous squamous cell carcinoma). The
lesions are indicated by arrows
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4 Terminology, Image Interpretation, andArtifacts forSkin Ultrasound
61
Irregular shape is characterized by lobulated or angular bulges with irregular boundary, such as squamous cell carcinoma
(Fig.4.6d).
Internal Composition
The internal composition refers to the composition of the lesion, which is divided into cystic,
solid, and mixed composition (Fig.4.7).
For solid lesions, it is necessary to describe
their internal echogenicity, such as hyperechogenicity, isoechogenicity, or hypoechogenicity,
and whether the echogenicity is uniform.
For the cystic part of the cystic lesions or the
mixed lesions, the degree of ultrasound transmission of the anechoic part needs to be described. In
general, anechogenicity with good ultrasound
transmission means that the internal uid is clear.
Conversely, hypoechogenicity or hyperechogenicity with poor ultrasound transmission means
that the internal uid is turbid or even gelatinous.
For the solid part of mixed lesions, the internal
shape needs to be described, such as papillary,
nodular, or septate. And the nodular solid part
should be further described according to the
requirements for solid nodules.
c
Fig. 4.7 Internal composition. (a) Solid lesions (cutane-
ous squamous cell carcinoma). (b) Cystic lesions with
banded septa inside (chronic inammatory lesions).
(c)Mixed lesions (cutaneous squamous cell carcinoma).
Arrows point to lesions, * point to the cystic areas