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Received: 4 February 2019    Revised: 26 February 2019    Accepted: 14 April 2019

DOI: 10.1111/srt.12708

ORIGINAL ARTICLE

High‐frequency ultrasonography a new quantitative method

in evaluation of skin lymphomas—First comparative study in
relation to histopathology

Adriana Polańska1  | Monika Bowszyc‐Dmochowska2 | Karolina Olek‐Hrab2 |

Zygmunt Adamski2 | Ryszard Żaba1 | Aleksandra Dańczak‐Pazdrowska2

1
Department of Dermatology and
Venereology, University of Medical
Sciences, Poznań, Poland
2
Department of Dermatology, University of
Medical Sciences, Poznań, Poland
Correspondence
Adriana Polańska, Department of
Dermatology and Venereology, University of
Medical Sciences, Poznań, Poland.
Email: adriana-polanska@wp.pl
Abstract
Introduction: High‐frequency ultrasonography (HF‐USG) is a noninvasive method
used in evaluation of depth and width of skin neoplasms. Recent data suggest that
this method may also supplement objective clinical assessment in skin lymphomas,
especially in mycosis fungoides, where subepidermal low echogenic band (SLEB) can
be observed. The aim of the study was to present characteristic ultrasonic picture of
MF in relation to histopathologic findings.
Materials and methods: Ten patients diagnosed as MF were included in the study.
The USG examination was performed with the use of 20 MHz transducer within rep‐
resentative plaque. From the scanning lesion, the skin biopsy was taken. The rela‐
tionship between histopathologic infiltrate with clonal T cells and USG image was
investigated.
Results: In all analyzed sonograms obtained from lesional skin of early‐stage MF, we
could detect the presence of subepidermal low echogenic band (SLEB). We detected
strong correlations between SLEB thickness and the thickness of subepidermal infil‐
tration (0.994, P < 0.05).
Conclusions: Subepidermal low echogenic band is a typical sign of infiltrative stage
of MF, and its thickness may depend on the type of skin lesion. HF‐USG may be a
reliable noninvasive method of quantitive assessments in MF, which corresponds to
the thickness on T‐cell infiltration in histopathology.

KEYWORDS
HF‐USG, high‐frequency ultrasonography, mycosis fungoides, skin lymphomas

1 |  I NTRO D U C TI O N
The introduction of high‐frequency ultrasonography (HF‐USG) in
1979 was the beginning of a new possibility of noninvasive imag‐
1
ing in dermatology. From simple measurement of skin thickness
up to evaluation of the depth of skin tumors, HF‐USG nowadays
constitutes an additional useful method in the evaluation of various
pathological processes located within the dermis and upper parts
of the subcutaneous tissue. 2,3 The maximum depth of 20 MHz ul‐
trasonic beam penetration is 15 mm. The USG image illustrates skin
components with different echogenicity, what is related to the his‐
topathologic division of skin into epidermis, dermis, and upper parts
of subcutaneous tissue. Upper layers of epidermis represent hyper‐
echogenic linear line (entrance echo), below which emerges dermis
as a less echogenic structure with scattered reflection.3,4 The border
between dermis and subcutaneous tissue is easily detected since the

Skin Res Technol. 2019;00:1–5. wileyonlinelibrary.com/journal/srt   © 2019 John Wiley & Sons A/S. |  1
Published by John Wiley & Sons Ltd
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2       POLAŃSKA et al.

second one is least echogenic. The echogenicity of the abovemen‐
5
tioned may vary according to the different processes affecting skin.
The noninvasiveness and reproducibility make HF‐USG espe‐
cially useful in oncological applications, mainly in melanoma and
nonmelanoma skin cancers (basal cell carcinoma), where strong
correlations were obtained between histological and ultrasono‐
graphic values of the tumoral thickness.6,7 While abovementioned
neoplasms are well recognized in dermatologic ultrasonography, still
limited data are available in regard to primary skin lymphomas, es‐
pecially in mycosis fungoides (MF), which constitutes nearly 44% of
all such diagnoses.8,9 The proper characterization of the type of skin
lesions in MF is of a great impact on the course and disease progno‐
sis. Different types of skin lesion present different prognosis, while
the classification of lesional skin into patch (flat lesion) or plaque (el‐
evated lesion) seems to be subjective and may be associated with
significant risk of disagreement.10 20‐MHZ USG has been previously
reported in our study to be useful in the evaluation of MF with a
11,12
possibility of monitoring the effects of therapies. The uniform
USG feature of infiltrative MF is the presence of linear low echo‐
genic band underneath entrance echo (subepidermal low echogenic
band, SLEB), which width may vary between different skin lesions
and severity of the disease.11,12 The relation between SLEB and infil‐
tration with clonal T cells is presumptive. The aim of the study was to
compare 20 MHz USG images of MF with histopathologic analysis.
2 |  M E TH O DS
Ten Caucasian patients (9 men, 1 woman, mean age 46, 5 years of
age) with early stages of mycosis fungoides (T1, T2) we enrolled to
the study. The characterization of the patients with the disease stag‐
ing according to the International Society for Cutaneous Lymphoma
(ISCL), European Society of Research and Treatment of Cancer
(EORTC), and Tumor‐Nodes‐Metastasis‐Blood (TNMB) is presented
in Table 1.13 In all patients, the disease was restricted to the skin.
There was no nodal, internal organs and blood involvement.
The study was approved by the local ethical committee, and all
patients provided written informed consent.
2.1 | 20 MHz USG
All patients underwent HF‐USG examination within representative
skin region (with the average severity of the disease). USG B‐mode
scans were performed using commercially available linear probe with
an axial resolution of 80 µm and lateral one of 200 µm. In A‐mode
scan, two parameters were analyzed. First one, the average width of
SLEB was evaluated by measuring the vertical distance between the
lower edge of the entry echo and the posterior margin of the hypo‐
echoic zone (parameter 1). The second parameter (parameter 2) was
calculated by measuring the vertical distance between upper edge
of the entry echo and the posterior margin of the hypoechoic band
(thus included entrance echo). All USG scan were performed by the
same trained physician.
2.2 | Histopathology
After performing USG examination, a 5‐mm punch biopsy from the
recorded skin area was taken. All specimens were fixated in 10%
buffered formalin and embedded in paraffin, and 3 µm sections
were stained with hematoxylin and eosin. Microscopical slides were
examined at ×100, ×200, and ×400 magnification of microscope
Olympus B×40. Two histopathologic parameters were calculated.
First one was the mean thickness of subepidermal infiltration with
clonal T cells (microscopy parameter 1), and the second was the
mean thickness of epidermis together with subepidermal neoplastic
infiltration (microscopy parameter 2).

TA B L E 1   Characteristics of the analyzed patients in regard to demographics, ISCL/EORTC, HF‐USG, and microscopic results

USG 1 USG 2
Type of examined parameter parameter Microscopy 1 Microscopy 2
No of patient Age Gender Tumor stage skin lesion* (mm) (mm) Parameter (mm) parameter (mm)

1 34 Male T1b Plague 1.087 1.104 0.9 1.0

2 62 Male T2b Plaque 0.208 0.413 0.1 0.4
3 43 Male T2b Patch 0.168 0.243 0.1 0.2
4 61 Female T2b Plaque 0.416 0.745 0.3 0.7
5 42 Male T2b Plaque 0.385 0.598 0.3 0.6
6 46 Male T2a Plaque 0.348 0.421 0.3 0.4
7 57 Male T2a Patch 0.362 0.312 0.32 0.28
8 49 Male T2b Plaque 0.924 0.579 0.8 0.5
9 52 Male T2b Plaque 0.469 0.3 0.4 0.2
10 53 Male T2a Plaque 0.512 0.489 0.45 0.4

Abbreviations 13: EORTC, European Society of Research and Treatment of Cancer; ISCL, International Society for Cutaneous Lymphoma; T1b,
patches and/or plaques covering <10% of the skin surface; T2a, patches covering >10% of the skin surface; T2b, patches and/or plaques covering
>10% of the skin surface.
*Type of examined lesion according ISCL and EORTC13 patch—every skin lesion (independently on its size) which is not elevated and indurated;
plague—every skin lesion (independently on its size) which is elevated or indurated.
POLAŃSKA et al.
2.3 | Statistical analysis
The differences in the mean of the studied variables, together with
the calculation of the statistical significance of this difference (test
for the equality of two means in dependent samples) were deter‐
mined. This step was preceded by the control of the normality of the
distribution of the difference of analyzed averages, carried out using
the Kolmogorov‐Smirnov test (with the correction of significance of
Lilliefors—due to the small sample size) and the Shapiro‐Wilk test.
Between the analyzed parameters, the Pearson correlation coeffi‐
cient was analyzed.
3 | R E S U LT S
3.1 | USG analysis
In all analyzed sonograms obtained from lesional skin, we could de‐
tect the presence of SLEB (Figure 1A). SLEB was sharply bordered
between hyperechoic entrance echo and surrounding dermis. The
mean value of SLEB (USG parameter 1) was 0.488 mm and was
thicker from plaque (mean value of plaque was 0.544 mm) than from
patch (0.265  mm). The mean value of second USG parameter (en‐
trance echo +SLEB) was 0.520 mm and was wider in plaque than in
patch (0.581 vs 0.277). There was no significant difference between
USG parameter 1 and 2 (P = 0.613).
3.2 | Histometry
In all skin biopsy, we observed infiltrates containing small and me‐
dium‐size T lymphocytes which were located subepidermally and
partially infiltrated epidermis (epidermotropic), what together is
(A)
(B)
F I G U R E 1   HF‐USG of plaque in MF (A) with corresponding
histopathology (B) in patient no 6 (magnification 100×)
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recognized as typical for stadium infiltrativum of MF (Figure 1B).
The histometry revealed that mean value of subepidermal infiltra‐
tion (microscopy parameter 1) was 0.397 mm, while mean value of
epidermis plus subepidermal infiltration was 0.468 mm. In plaques,
both microscopic parameters were wider than in patches (0.444 and
0.525 mm; 0.21 and 0.24 mm; respectively). There was no significant
difference between microscopic parameter 1 and 2 (P = 0.343).
The ultrasonographic parameters were statistically wider than
microscopic one (for both parameters P < 0.05). We detected strong
correlations between analyzed parameters [USG parameter 1 cor‐
related with microscopy 1 parameter (0.994, P < 0.05) and USG 2
parameter correlated with microscopy 2 (0.989, P < 0.05).
The relationship between sonometry and histopathology in pa‐
tient 6 is presented in Figure 1A and B.
4 | D I S CU S S I O N
Data considering the use of noninvasive tools in skin lymphomas are
spared. The recently evaluated method in MF and lymphomatoid
papulosis is reflectance confocal microscopy (RCM), which presents
strong correlation with histology.14 However, RCM compared with
HF‐USG is a time‐consuming procedure. In HF‐USG, the characteris‐
tic feature of all early stages of MF is the presence of SLEB of varied
thickness.
Subepidermal low echogenic band is a sonographic phenomenon
highlighting the presence of the subepidermal anechogenic or low
echogenic band underneath the entrance echo and has low specific‐
ity.3-5 Its first description was in 1989 by de Rigal et al15 within sun‐
exposed skin. Its origin as a marker of photodamaged skin is not well
understood, and probably, it is derived from skin elastosis and ac‐
cumulation of glycosaminoglycans, which possess increased water‐
binding capacity.16 According to the literature, SLEB can be also
caused by inflammation/edema in many conditions such as atopic
dermatitis, eczema, or psoriasis.17-19 The decreased echogenicity can
be detected as a typical ultrasound aspect of positive patch test. 20
Our previous studies revealed that in MF we can monitor pa‐
tients’ response to different modalities on the base of the change
of the mean SLEB value and that SLEB is related to the severity of
the disease.11,12 After completion of UV therapy in all subjects, SLEB
decreased or disappeared completely what was related to clinical
evaluation.11,12 We speculated that SLEB probably reflects the in‐
filtration with clonal T cells of the upper parts of the dermis and
its thinning or even complete disappearance may be observed after
successful treatment and may serve as a useful indicator of effec‐
tiveness of therapy. However, the exact correspondence between
SLEB and histological features in MF has not been evaluated until
now. That is why for the first time we decided to compare histome‐
try with ultasonographic features of MF.
In this study, we found that mean SLEB value was wider than
the measurement of subepidermal T‐cell infiltration in skin biopsy.
Similarly, second ultrasonographic parameter was significantly wider
than the corresponding microscopic one. Despite the differences,
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4       POLAŃSKA et al.
we revealed the strong correlations between analyzed techniques.
The difference between measurements (ultrasonographic and histo‐
metric) may be related to the shrinkage of the specimen during its
preparation. This problem was observed previously in relation to
BCC and melanomas.5-7,21 It was reported before, that routine his‐
tology process may distort anatomy of the skin and result in contrac‐
tion of the tissue—particularly evident for the dermis (especially in
relation to elastic fibers) and, what is more, ultrasound in vivo mea‐
surement was proposed as more reliable method in the determina‐
21
tion of true tumor extent.
We showed that both ultrasonographic parameters may be used
in evaluation of the process in MF. The inclusion of the entrance
echo in measurements did not differ from the use of SLEB only. The
entrance echo is mainly formed by upper parts of the epidermis,
which are the dead cells, while dermo‐epidermal junction cannot be
visualized. So it is not corresponding to the whole epidermis forms
histopathologic point of view.
In this study, we additionally observed the relation between SLEB
and type of skin lesion—SLEB value in plaque (which is an elevated
lesion) was thicker than in patch (flat lesion). Although, the limitation
is small sample of analyzed cases, it may seem that sonometry may be
more accurate in determination of the type of skin lesions than clini‐
cal assessment (palpation or observation especially made by nonder‐
matologist) and should complement the evaluation of patients eligible
for clinical trials. Commonly used systems for patients’ evaluation in
MF are based on clinical (naked‐eye) evaluation of the extent and
type of skin lesion (mSWAT, modified Severity‐Weighted Assessment
Tool).13 Taken into consideration that MF clinically may present with
different types of skin lesions, the objective evaluation on the base
of mSWAT seems to present low reproducibility. According to guide‐
lines, skin lesions are classified into group T1a, b (a—only patches,
b—patches and/or plaques involving <10% of skin surface) and T2
a, b (a—only patches, b—patches and/or plaques involving >10% of
body surface).13 Detail classification of the patients regarding type of
skin lesion is clinically important because is associated with different
treatment possibilities and is related to long‐term prognosis (worse
prognosis in patients with plaques).22 Recent studies showed that
crude concordance between two dermatologists regarding patch‐
plaque status was 86%.10 Also there are reports showing difficulty
in distinguishing between plaque and patch. The introduction of HF‐
USG into the grading of skin lymphomas, from our point of view, may
increase objectivity and repeatability of the patient evaluations. We
suggest that in evaluation of MF [similarly to other skin condition, like
psoriasis, where it is recommended to use 3 different scales in eval‐
uation of patients' clinical state—body surface area, Psoriasis Area
Severity Index (PASI), and Life Quality Index] we should not only rely
on mSWAT, but broaden overall evaluation also on HF‐USG.
5 |  CO N C LU S I O N S
We present two sonometric parameters useful in MF. The limitation
of our study is small number of included patients, and the observed
herein results should be confirmed on bigger sample of patients.
However, we can conclude that our findings show good agreement
between sonometric and histopathologic features in MF what makes
HF‐USG a suitable tool in noninvasive quantitative evaluation of pa‐
tients with MF.
ORCID
Adriana Polańska  https://orcid.org/0000-0001-9531-7358
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How to cite this article: Polańska A, Bowszyc‐Dmochowska
M, Olek‐Hrab K, Adamski Z, Żaba R, Dańczak‐Pazdrowska A.
High‐frequency ultrasonography a new quantitative method
in evaluation of skin lymphomas—First comparative study in
relation to histopathology. Skin Res Technol. 2019;00:1–5.
https​://doi.org/10.1111/srt.12708​