19 October 2016 - Case of the Week #405

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Case of the Week #405

Clinical history:
A 57 year old man with biopsy proven GE junction adenocarcinoma subsequently received neoadjuvant therapy, followed by a resection, which showed no residual disease. Microscopic sections are shown from regional lymph nodes.


Micro images:



What is your diagnosis?































Diagnosis:
Vascular transformation of sinuses / nodal angiomatosis


Discussion:
Vascular transformation of (lymph node) sinuses is usually an incidental finding in lymph nodes examined with resections for unrelated conditions (e.g. malignancy) or biopsied as part of the work up of suspected malignancy due to easy accessibility. It is apparently due to lymphatic or venous obstruction. There are no pathognomonic gross findings although the lymph nodes may appear grossly enlarged. On microscopic examination, anastomosing vascular channels are present limited to the subcapsular and medullary sinuses of the node. The channels may be vascular or lymphatic, and involvement varies from focal to diffuse. Fibrosis is variable (Am J Surg Pathol 1991;15:732).

The differential diagnosis includes:
Angiomyomatous hamartoma: inguinal nodes in males, includes adipose and smooth muscle elements in addition to fibrosis and vessels
Angiosarcoma: usually metastatic, vascular channels lined by obviously malignant atypical cells
Composite hemangioendothelioma: rare, low grade, usually presents as a metastasis from a soft tissue primary
Kaposi sarcoma (primary nodal): predominantly children, atypical spindle cells forming slit-like vascular channels, occasionally with prominent mitoses, extravasated red cells
Lymphangioma
Polymorphous hemangioendothelioma: sheets and cords of plump spindle cells with nuclear pleomorphism and abundant cytoplasm sometimes with vacuoles containing red cells, set in a myxohyaline stroma
Endovascular papillary hemangioendothelioma: a.k.a Dabska tumor, low grade, rare type of angiosarcoma with anastomosing vascular spaces with intravascular papillary outpouchings which may result in a glomerulus-like pattern (Arch Pathol Lab Med 2012;136:110).

No treatment is required for this benign condition.


Discussion by: Dr. Belinda Lategan, St. Boniface Hospital (Canada)