The Rest of the Story

A 58 year old woman underwent a core biopsy of a mass.  That case was presented in the Interesting Case Series June 27, 2016, entitled “Reactive or Neoplastic Metaplastic Lesion?"

…..And now for the rest of the story…..

Following the initial diagnosis of low grade adenosquamous carcinoma, the patient underwent a core biopsy of an enlarged lymph node (image 1) as well as a separate breast nodule (core biopsy of second breast lesion not shown).

The patient then underwent lumpectomy (images 2-5), and limited lymph node dissection (image 6).

Image 1.  The core biopsy of the lymph node contains epithelium, with areas of squamous metaplasia.

Image 3.  Bland glandular structures, spindled cells and squamoid nests are characteristic of this special type low grade metaplastic carcinoma.  Previously, immunohistochemical studies had been performed on the core biopsy specimen which showed the spindled cells to express p63 and cytokeratins.

Image 3.  Bland glandular structures, spindled cells and squamoid nests are characteristic of this special type low grade metaplastic carcinoma.  Previously, immunohistochemical studies had been performed on the core biopsy specimen which showed the spindled cells to express p63 and cytokeratins.

Image 5.  There is minimal epithelial proliferation associated with this benign intraductal papilloma.

Image 7.

Image 2.  The low grade adenosquamous carcinoma, originally diagnosed on core biopsy was present in the lumpectomy specimen. Note previous biopsy site

Image 4.  The previously biopsied second breast nodule is an intraductal papilloma; note biopsy site changes.

Image 6.  One of eight lymph nodes contained epithelium, similar to that seen in the core biopsy of the enlarged lymph node (image 1).  Note papillary architecture.

Image 8.

Image 7-8.  Immunohistochemical studies using antibodies to p63 were performed on the lymph node core biopsy (image 7) as well as the lymph node removed at the time of lumpectomy (image 8).  Maintenance of myoepithelial cells is present, supporting the histologic diagnosis of benign breast epithelium within the lymph node. 


Discussion:  Although uncommon, axillary lymph nodes may contain breast tissue, usually in the form of benign glandular inclusions, but occasionally intraductal papillomas may be present (see Interesting Case Series, “a staging paradox’, December 26,  2015".  The latter finding occurs most often when the ipsilateral breast contains intraductal papillomas, as occurred in the current case.  Recognition of this phenomenon can avoid over-diagnosis of metastasis.  

Reference:  Boulos FI, et al.  Intranodal papillary epithelial proliferations: a local process with a spectrum of morphologies and frequent association with papillomas in the breast. Am J Surg Pathol. 2014 Mar;38(3):383-8.