The diagnosis and management of primary cutaneous melanoma have traditionally relied on clinical and histological characteristics. Nevertheless, in recent years there has been a significant growth in the usage of ultrasound for studying the cutaneous layers. Thus, the present paper focuses on the primary lesion, its sonographic characteristics, the potential benefits of early imaging, and the new developments on the ultrasound field applied to cutaneous melanoma. 1. Introduction Cutaneous malignant melanoma constitutes 4 to 11% of all skin cancers but is responsible for more than 75% of skin cancer-related deaths producing more than 8000 deaths per year in the United States . To date the diagnosis is clinical, and the usage of ultrasound in the study of cutaneous melanoma has been focused more on the locoregional staging than on the primary lesion, and the prognosis being mainly assessed by clinical and histological features. The staging of melanoma is mostly based on the Breslow classification that relies on sequential tumor infiltration (depth) by histology within the different cutaneous layers, providing a measurement of the microscopic invasion from the stratum granulosum of the epidermis to the deepest portion of the tumor . The Breslow index has been reported to correlate well with the prognosis of the disease. Moreover, according to the thickness of the primary tumor, important decisions are taken such as the size of the excision and the free margins or the requirement for a sentinel lymph node procedure. Nevertheless, there are controversial reports about the appropriate size of the excision that should be performed on melanoma. Hence, a small (but potentially important) difference in overall survival between wide and narrow excision margins has been reported that cannot be confidently ruled out. Literature has mentioned that recurrence-free survival is favored with wide excision (Hazard Ratio 1.13; ; 95% confidence interval 0.99 to 1.28) but the results have not reached statistical significance ( level). Furthermore, randomized trial evidence seems to be insufficient to address optimal excision margins for primary cutaneous melanoma . Reports on recurrence rates in melanoma have shown a wide range depending on the stage of the primary tumor; thus, they can vary from 7.1% in stage I to 51% in stage III . Moreover, older patients with thicker tumors and angiolymphatic invasion appear to be at higher risk for local and in-transit recurrence . Hence, the appearance of in-transit metastasis seems to be linked to the biological
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