Breast – Malignant, Males, Children - Axillary lymph node examination

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Breast-malignant, males, children

Axillary lymph node examination

Author: Nat Pernick, M.D, PathologyOutlines.com, Inc.

Reviewer: Daniel Visscher, M.D., University of Michigan Hospitals, February 2009 (see Reviewers page)

Revised: 27 August 2009

Last major update: August 2009

See also Sentinel Nodes

Terminology

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● Micrometastases: 2 mm or less

● Isolated tumor cells: 0.2 mm or less

Clinical

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● Presence of axillary lymph node metastases is the most important prognostic factor for disease-free and overall survival, and important for determining treatment

● Presurgical staging of axillary nodes (ultrasound with FNA) is increasingly popular (Cancer 2008;114:89)

● Axillary nodal dissection may not be indicated if negative sentinel node examination, even if false-negative (Breast Cancer 2009 Aug 22 [Epub ahead of print], Eur J Cancer 2009;45:1381)

● Occult metastases (identified retrospectively by step-sectioning and immunohistochemical staining) are an independent predictor of disease-free survival, but not overall survival, in node-negative patients, particularly if > 0.5 mm (AJSP 2002;26:1286)

● Significance of micrometastases is controversial (Arch Pathol Lab Med 2009;133:869)

● Clearing solutions, such as ethanol, diethyl ether, Carnoy’s solution (Chin Med J (Engl) 2007;120:1762), glacial acetic acid and formalin may identify additional lymph nodes (AJSP 1997;21:1387, Archives 2001;125:642)

● Neoadjuvant chemotherapy may be associated with identification of fewer lymph nodes (J Am Coll Surg 2008;206:704), but see Am J Surg 2009;198:46

● Regional lymph nodes are:

(1) Axillary (ipsilateral), subdivided as follows (image):

Level I (low axilla): lateral to the lateral border of pectoralis minor muscle

Level II (mid axilla): between medial and lateral borders of pectoralis minor muscle, plus the interpectoral (Rotter’s) lymph nodes

Level III (apical axilla): medial to the medial margin of the pectoralis minor muscle, including those designated as apical, excluding those designated as subclavicular or infraclavicular

(2) Infraclavicular (subclavicular) (ipsilateral)

(3) Internal mammary (ipsilateral): lymph nodes in the intercostal spaces along the edge of the sternum in the endothoracic fascia

(4) Supraclavicular (ipsilateral)

● Side effects of axillary nodal dissection include lymphedema, shoulder restriction, numbness, weakness and pain syndromes (Cancer J 2008;14:216)

Case reports

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● Melanoma and breast ductal carcinoma metastasizing to same node (Int Semin Surg Oncol 2006;3:32)

● DCIS arising in intraductal papilloma in axillary lymph node (Arch Pathol Lab Med 2008;132:1940)

● Sclerosing adenosis in axillary lymph node (Arch Pathol Lab Med 2008;132:1439)

Micro images

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Axillary nodal metastases Resembles large cell Metastatic breast carcinoma

lymphoma and melanoma

Subcapsular metastasis: H&E and keratin Metastatic tumor (A) with

adjacent histiocytes (B)

Various images Metastatic carcinoma,

benign inclusions and nevus cells

False positives (i.e. not metastatic breast carcinoma)

Intramammary lymph node Metastatic ovarian serous papillary adenocarcinoma

DCIS arising in intraductal papilloma Sclerosing adenosis

Benign epithelial inclusions - Fig 1: CK 5/6+; Fig 2: p63+

Heterotopic glands with structure #2 – myoepithelial cells (arrows) and

of mammary lobule #1 basement membrane are present

Lactational histiocytosis Histiocytes (FNA)

Clusters of nevus cells have indistinct cell borders and small uniform nuclei,

and are S100+ (as are histiocytes)

Hemangioma

Tattoo pigment Lipogranulomatosis due to

triglyceride filled breast implant

Features of chronic lymphedema of arm:

Hyperkeratosis, thickened dermis with Pseudoepitheliomatous hyperplasia,

edema, elastosis, fibrosis, congested hyperkeratosis, dilated dermal vascular

capillaries (arrow) and lymphocytes channels

Dilated dermal vascular channels with

prominent endothelial cells

Cytology images

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Malignant epithelial cells in FNA

(top/middle); bottom (H&E) shows

chemotherapy related changes

in excised lymph node

Videos

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● Axillary nodal metastases #1; #2

Differential diagnosis

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● Benign transport after prior breast biopsy (AJCP 2000;114:190)

● Ectopic breast tissue (Breast Cancer 2007;14:425)

● Mullerian-type epithelial inclusions - have myoepithelial cells which are p63+ and smooth muscle myosin+ (Archives 2004;128:361, Archives 1995;119:841, Am J Clin Pathol 2008;130:21)

● Muciphages - resemble signet-ring carcinoma, associated with prior surgery or lactation, Alcian blue+, CD68+, Mac387+, keratin-, (AJSP 1998;22:545)

● Nevus cells (AJCP 1994;102:102, AJSP 2003;27:673, Archives 1985;109:1044)

End of Breast – Malignant, Males, Children > Axillary lymph node examination

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