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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Merkel cell carcinoma &#40;MCC&#41; is a rare&#44; fast-growing&#44; aggressive neuroendocrine tumor that frequently causes locoregional recurrence and distant metastasis&#46; It tends to affect sun-exposed areas &#40;mainly the head&#44; neck&#44; and upper extremities&#41; and associated risk factors include immune suppression&#44; elderly age&#44; fair skin&#44; and a history of prior malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Imaging modalities used to stage disease and plan surgery include computed tomography and magnetic resonance imaging&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> but very few studies have described the ultrasound features of MCC&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the ultrasound findings of 5 cases of primary MCC analyzed using an 18-MHz linear transducer&#46; In all cases&#44; diagnosis was confirmed by preoperative skin biopsy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">B-mode imaging showed well-defined&#44; hypoechoic dermal and hypodermal lesions&#46; Two of the tumors had homogeneous content&#46; The other 3 were heterogeneous and contained hyperechoic septae in 1 case and hypoechoic lines running perpendicular to the skin surface in the other 2&#46; The B-mode images also showed posterior acoustic enhancement in 3 of the tumors and thinning of the overlying epidermis in 2&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most of the tumors had intense intralesional hypervascularity on color Doppler ultrasound&#46; The vascular structures were predominant in the basal area of all tumors except the one in which hyperechoic lines had been observed by B-mode ultrasound&#46; In this case&#44; a strong Doppler signal was detected among the septae &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A full histologic examination was possible in 3 of the tumors&#59; the other 2 &#40;cases 2 and 5&#41; regressed spontaneously after the skin biopsy &#40;diagnosis was confirmed by histologic examination of the surgical specimen&#41;&#46; Three of the tumors showed a solid growth pattern&#46; One had spiculated margins and the other 2 had better defined margins and a lobular structure&#46; All 3 tumors had fibrous trabeculae separating the cells&#59; the first tumor had fine bands with scant vascular structures&#44; while the other 2 had thick fibrous bands containing numerous vascular structures &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; All 5 tumors were studied by immunohistochemistry and were positive for chromogranin&#44; synaptophysin&#44; and CD56&#46; Paranuclear staining was observed for cytokeratin 20 and negative results were detected for CD45&#44; S-100 protein&#44; and thyroid transcription factor 1&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">There are very few descriptions of the ultrasound features of MCC in the literature&#44; as ultrasound is mainly used to study locoregional lymph nodes in this setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> Wortsman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> described hypoechoic dermal and hypodermal lesions with ill-defined margins and intense hypervascularity&#46; Although the ultrasound findings for the 5 tumors in our series were quite diverse&#44; they all had similar characteristics to those described in the literature&#44; except for the tumor margins&#44; which were well-defined in all cases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Other common ultrasound findings reported for MCC&#44; and also observed in our series&#44; are posterior acoustic reinforcement and thinning of the overlying epidermis&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#8211;9</span></a> In a recent article&#44; Hern&#225;ndez-Arag&#252;&#233;s et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> described hypoechoic linear bands with a plume-of-smoke appearance perpendicular to the skin surface in 2 cases of primary MCC&#59; Doppler imaging showed vascularity in these areas&#46; Two of the tumors in our series had hypoechoic bands&#44; but the vascular structures were located elsewhere&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Histologically&#44; 2 of the tumors in our series &#40;the one with the plume-of-smoke appearance on ultrasound and the one containing hyperechoic septae&#41; had thick fibrous bands separating the cells&#46; Although these fibrous trabeculae featuring abundant vascular structures appeared to correspond to the perpendicular hypoechoic lines and the hyperechoic septae detected by ultrasound&#44; we found no histologic differences to explain the different echogenicity of these structures&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; our analysis of the 5 cases in our series and those reported in the literature did not reveal a distinctive ultrasound pattern for MCC and we were also unable to determine the diagnostic and prognostic significance of some of the features observed&#46; Notwithstanding&#44; skin ultrasound is undoubtedly a useful imaging tool for determining tumor location&#44; extension&#44; vascularity&#44; and relationship to adjacent structures&#46; As such&#44; it can aid in the planning of surgery&#46; In addition&#44; it provides an objective measure of tumor size and extent of deep invasion and can also identify subcutaneous or in-transit metastases&#44; enabling better staging and providing preliminary prognostic information&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Harana C&#44; Fernandez-Canedo I&#44; Rodriguez-Lobalzo S&#44; de Troya-Mart&#237;n M&#46; Carcinoma de c&#233;lulas de Merkel&#58; &#191;existe un patr&#243;n ecogr&#225;fico distintivo&#63;&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;503&#8211;506&#46;</p>"
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Case and Research Letter
Merkel Cell Carcinoma: Is There a Distinctive Ultrasound Pattern?
Carcinoma de células de Merkel: ¿existe un patrón ecográfico distintivo?
C. García-Haranaa,
Autor para correspondencia
cristina.garciaharana@gmail.com

Corresponding author.
, I. Fernandez-Canedoa, S. Rodriguez-Lobalzob, M. de Troya-Martína
a Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, Spain
b Servicio de Anatomía Patológica, Hospital Costa del Sol, Marbella, Málaga, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Case 1&#58; Lesion with solid growth pattern and slightly spiculated margins &#40;hematoxylin-eosin &#91;H-E&#41;&#59; B&#44; Detail of fibrous trabeculae in the form of fine bands with scant vascular structures &#40;H-E&#44; original magnification &#215;100&#41;&#59; C &#40;case 3&#41;&#44; Tumor with clearer margins and a lobular structure with fibrous bands that appear to correspond to the hyperechogenic intralesional lines observed by B-mode ultrasound &#40;H-E&#41;&#59; D&#44; Detail of thick fibrous bands containing numerous vascular structures &#40;H-E&#44; original magnification &#215;40&#41;&#59; E &#40;case 4&#41;&#44; Lobular lesion with a thick fibrous band perpendicular to the epidermis that appears to correspond to the hypoechoic line detected by B mode ultrasound&#59; F&#44; Detail of thick central fibrous band with wider vascular structures than in case 3 &#40;H-E&#44; original magnification &#215;100&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Merkel cell carcinoma &#40;MCC&#41; is a rare&#44; fast-growing&#44; aggressive neuroendocrine tumor that frequently causes locoregional recurrence and distant metastasis&#46; It tends to affect sun-exposed areas &#40;mainly the head&#44; neck&#44; and upper extremities&#41; and associated risk factors include immune suppression&#44; elderly age&#44; fair skin&#44; and a history of prior malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Imaging modalities used to stage disease and plan surgery include computed tomography and magnetic resonance imaging&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> but very few studies have described the ultrasound features of MCC&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the ultrasound findings of 5 cases of primary MCC analyzed using an 18-MHz linear transducer&#46; In all cases&#44; diagnosis was confirmed by preoperative skin biopsy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">B-mode imaging showed well-defined&#44; hypoechoic dermal and hypodermal lesions&#46; Two of the tumors had homogeneous content&#46; The other 3 were heterogeneous and contained hyperechoic septae in 1 case and hypoechoic lines running perpendicular to the skin surface in the other 2&#46; The B-mode images also showed posterior acoustic enhancement in 3 of the tumors and thinning of the overlying epidermis in 2&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most of the tumors had intense intralesional hypervascularity on color Doppler ultrasound&#46; The vascular structures were predominant in the basal area of all tumors except the one in which hyperechoic lines had been observed by B-mode ultrasound&#46; In this case&#44; a strong Doppler signal was detected among the septae &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A full histologic examination was possible in 3 of the tumors&#59; the other 2 &#40;cases 2 and 5&#41; regressed spontaneously after the skin biopsy &#40;diagnosis was confirmed by histologic examination of the surgical specimen&#41;&#46; Three of the tumors showed a solid growth pattern&#46; One had spiculated margins and the other 2 had better defined margins and a lobular structure&#46; All 3 tumors had fibrous trabeculae separating the cells&#59; the first tumor had fine bands with scant vascular structures&#44; while the other 2 had thick fibrous bands containing numerous vascular structures &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; All 5 tumors were studied by immunohistochemistry and were positive for chromogranin&#44; synaptophysin&#44; and CD56&#46; Paranuclear staining was observed for cytokeratin 20 and negative results were detected for CD45&#44; S-100 protein&#44; and thyroid transcription factor 1&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">There are very few descriptions of the ultrasound features of MCC in the literature&#44; as ultrasound is mainly used to study locoregional lymph nodes in this setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> Wortsman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> described hypoechoic dermal and hypodermal lesions with ill-defined margins and intense hypervascularity&#46; Although the ultrasound findings for the 5 tumors in our series were quite diverse&#44; they all had similar characteristics to those described in the literature&#44; except for the tumor margins&#44; which were well-defined in all cases&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Other common ultrasound findings reported for MCC&#44; and also observed in our series&#44; are posterior acoustic reinforcement and thinning of the overlying epidermis&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#8211;9</span></a> In a recent article&#44; Hern&#225;ndez-Arag&#252;&#233;s et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> described hypoechoic linear bands with a plume-of-smoke appearance perpendicular to the skin surface in 2 cases of primary MCC&#59; Doppler imaging showed vascularity in these areas&#46; Two of the tumors in our series had hypoechoic bands&#44; but the vascular structures were located elsewhere&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Histologically&#44; 2 of the tumors in our series &#40;the one with the plume-of-smoke appearance on ultrasound and the one containing hyperechoic septae&#41; had thick fibrous bands separating the cells&#46; Although these fibrous trabeculae featuring abundant vascular structures appeared to correspond to the perpendicular hypoechoic lines and the hyperechoic septae detected by ultrasound&#44; we found no histologic differences to explain the different echogenicity of these structures&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; our analysis of the 5 cases in our series and those reported in the literature did not reveal a distinctive ultrasound pattern for MCC and we were also unable to determine the diagnostic and prognostic significance of some of the features observed&#46; Notwithstanding&#44; skin ultrasound is undoubtedly a useful imaging tool for determining tumor location&#44; extension&#44; vascularity&#44; and relationship to adjacent structures&#46; As such&#44; it can aid in the planning of surgery&#46; In addition&#44; it provides an objective measure of tumor size and extent of deep invasion and can also identify subcutaneous or in-transit metastases&#44; enabling better staging and providing preliminary prognostic information&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A &#40;case 1&#41;&#44; Firm&#44; indurated&#44; erythematous lesion with a diameter of 1<span class="elsevierStyleHsp" style=""></span>cm on the left side of the lower lip&#59; B&#44; B-mode image showing a homogeneous hypoechoic dermal lesion with well-defined margins&#59; C&#44; Color Doppler image showing predominant hypervascularity in the basal area&#59; D &#40;case 2&#41;&#44; Subcutaneous nodule with a diameter of 8<span class="elsevierStyleHsp" style=""></span>mm located in the right parietal region and covered by pink skin&#59; E&#44; B-mode image showing a hypoechoic dermal&#47;epidermal lesion&#59; F&#44; Color Doppler image showing a weak signal around the lesion&#59; G &#40;case 3&#41;&#44; Pink nodule with a diameter of 18<span class="elsevierStyleHsp" style=""></span>mm on the internal aspect of the right thigh&#59; H&#44; B-mode image showing a hypoechoic polylobular dermal&#47;hypodermal lesion with well-defined margins&#44; posterior acoustic reinforcement&#44; and predominant intralesional vascularity in the septae&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A &#40;case 4&#41;&#44; Subcutaneous lesion with a diameter of 20<span class="elsevierStyleHsp" style=""></span>mm&#44; an elastic consistency&#44; and a violaceous surface on the right buttock&#59; B&#44; B-mode image showing a hypoechoic hypodermal lesion with heterogeneous content and hypoechoic plume-of-smoke lines running perpendicular to the epidermis&#44; well-defined margins&#44; and posterior acoustic reinforcement&#59; C&#44; Color Doppler image showing intralesional vascularity&#59; D &#40;case 5&#41;&#44; Erythematous nodule over a subcutaneous lesion with a diameter of a 22<span class="elsevierStyleHsp" style=""></span>mm on the left cheek&#59; E&#44; B-mode image showing a hypoechoic dermal lesion with heterogeneous content and hypoechoic plume-of-smoke lines running perpendicular to the epidermis&#59; F&#44; Color Doppler image showing predominant intralesional vascularity in the basal area&#46;</p>"
        ]
      ]
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        "etiqueta" => "Figure 3"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Case 1&#58; Lesion with solid growth pattern and slightly spiculated margins &#40;hematoxylin-eosin &#91;H-E&#41;&#59; B&#44; Detail of fibrous trabeculae in the form of fine bands with scant vascular structures &#40;H-E&#44; original magnification &#215;100&#41;&#59; C &#40;case 3&#41;&#44; Tumor with clearer margins and a lobular structure with fibrous bands that appear to correspond to the hyperechogenic intralesional lines observed by B-mode ultrasound &#40;H-E&#41;&#59; D&#44; Detail of thick fibrous bands containing numerous vascular structures &#40;H-E&#44; original magnification &#215;40&#41;&#59; E &#40;case 4&#41;&#44; Lobular lesion with a thick fibrous band perpendicular to the epidermis that appears to correspond to the hypoechoic line detected by B mode ultrasound&#59; F&#44; Detail of thick central fibrous band with wider vascular structures than in case 3 &#40;H-E&#44; original magnification &#215;100&#41;&#46;</p>"
        ]
      ]
    ]
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