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Breast malignant, males, children

Breast cancer

Axillary lymph node examination


Reviewer: Monika Roychowdhury, M.D. (see Reviewers page)
Revised: 19 December 2012, last major update January 2012
Copyright: (c) 2001-2012, PathologyOutlines.com, Inc.

See also Sentinel Nodes

Terminology
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● Macrometastases: >2mm
● Micrometastases: 2 mm or less
● Isolated tumor cells: 0.2 mm or less

Clinical description
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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 2010;17:9, 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 (Am J Surg Pathol 2002;26:1286); recent study reports no prognostic significance of occult metastasis in early stage breast cancer (Cancer 2011 Aug 25 [Epub ahead of print])
● 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 (Am J Surg Pathol 1997;21:1387, Arch Pathol Lab Med 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)
● Dissection of the brachial, acromiothoracic, humeral, Rotter's and scapular lymph nodes is recommended for proper staging (J Egypt Natl Canc Inst 2011;23:25)

Case reports
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● 52 year old woman with submental lymph node metastasis from invasive ductal breast cancer (Arch Gynecol Obstet 2011 Sep 9 [Epub ahead of print])
● 55 year old woman with DCIS arising in intraductal papilloma in axillary lymph node (Arch Pathol Lab Med 2008;132:1940)
● 58 year old woman with melanoma and breast ductal carcinoma metastasizing to same node (Int Semin Surg Oncol 2006;3:32)
● 82 year old woman with sclerosing adenosis in axillary lymph node (Arch Pathol Lab Med 2008;132:1439)

Micro images
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Axillary nodal metastases


Metastatic breast carcinoma 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+

   
Left: heterotopic glands with structure of mammary lobule
Right: myoepithelial cells (arrows) and 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 edema, elastosis, fibrosis,
congested capillaries (arrow) and lymphocytes



Pseudoepitheliomatous hyperplasia, hyperkeratosis, dilated dermal vascular channels


Dilated dermal vascular channels with prominent endothelial cells

Cytology images
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Various images

Videos
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Axillary nodal metastases #1; #2

Differential diagnosis
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● Benign transport after prior breast biopsy (Am J Clin Pathol 2000;113:259)
● Ectopic breast tissue (Breast Cancer 2007;14:425)
● Mullerian-type epithelial inclusions: have myoepithelial cells which are p63+ and smooth muscle myosin+ (Arch Pathol Lab Med 2004;128:361, Arch Pathol Lab Med 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- (Am J Surg Pathol 1998;22:545)
● Nevus cells (Am J Clin Pathol 1994;102:102, Am J Surg Pathol 2003;27:673, Arch Pathol Lab Med 1985;109:1044)

End of Breast malignant, males, children > Breast cancer > Axillary lymph node examination


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