509008
research-article2013
IJSXXX10.1177/1066896913509008International Journal of Surgical PathologyBegum et al
Case Report
Nodal Combined Blue Nevus and Benign Nevus Cells in Multiple Axillary Sentinel Nodes in a Patient With Breast Carcinoma: Report of a Case
International Journal of Surgical Pathology 2014, Vol. 22(6) 570–573 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896913509008 ijs.sagepub.com
S. M. K. Nahar Begum, MBBS, MPhil1, Michele Lomme, MD1, and M. Ruhul Quddus, MD, MPhil1
Abstract Combined blue nevus and benign nevus cells were identified in the same sentinel lymph node. Blue nevus alone was also present in an additional sentinel lymph node in the same axilla in a patient who underwent needle localization, wide local excision, and sentinel lymph node biopsy for her pT1cN1mi(sn)M(na) invasive duct carcinoma of the breast. Of the 4 sentinel lymph nodes, 1 showed micrometastasis and 2 other lymph nodes showed blue nevus involving the capsule and trabeculae of the nodes. The patient had no significant previous clinical history of any skin tumors and had a negative clinical examination for malignant melanoma or pigmented skin lesions after the diagnosis of nodal blue nevus. To our knowledge, this is the first case report of combined blue nevi involving multiple sentinel lymph nodes in the same axilla. An equally interesting finding is the presence of benign nonpigmented nevus cells in continuation with the blue nevus in the same node. Keywords nodal combined blue nevus, benign nevus cells, sentinel node, breast cancer
Introduction
Case Report
The report of benign nevus cells, in the hilar connective tissue of axillary lymph node, was published by Stewart and Copeland1 in 1931. It is also well documented that benign nevus cells are found within the capsule and trabeculae of axillary lymph nodes.2 Biddle et al2 also reported intraparenchymal nevus cell aggregates in lymph nodes. Epstein et al3 reported 3 cases of blue nevus and documented that only 1 lymph node in each axilla was involved by blue nevus. Azzopardi et al4 were the first to report blue nevus in the capsule and fibrous trabeculae of the lymph nodes and 1 of the 2 cases reported had an ordinary blue nevus in the skin. Lambert and Brodkin5 also reported a cellular blue nevus in inguinal lymph node of a 20-year-old white woman, which was initially thought to be “metastatic melanoma” and the patient was subject to unnecessary surgery. The report of Lambert and Brodkin emphasizes the importance of correctly recognizing the blue nevus in lymph nodes and not to overdiagnose the lesion as metastatic disease. The incidence of benign nevus cells varies from 0.33% to 7.3% in cases other than melanoma6-8 and as high as 22% in cases of malignant melanoma.9
A 53-year-old, gravid 4 para 2 white woman presented with an abnormal mammogram showing architectural distortion in her right breast and a hypoechoic spiculated mass at 9 o’clock. On examination, the breasts are symmetrical, soft, and nontender. Manual examination did not reveal any palpable breast mass and no palpable axillary lymph nodes were detected. The patient had no significant previous clinical history of any skin tumors and negative clinical examination for malignant melanoma or any pigmented of the skin after the nodal combined blue nevus was detected in axillary sentinel lymph node. Her menarche was at age 14 and had a vaginal hysterectomy 6 years ago because of benign disease. The ovaries 1
Warren Alpert Medical School of Brown University, Providence, RI, USA Corresponding Author: M. Ruhul Quddus, Department of Pathology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI 02905, USA. Email: [email protected]
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
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Begum et al were not removed. Two paternal aunts had breast cancer diagnosed in their 70s; both of them are alive and well at 88 and 76 years of age with no evidence of diseases. Wide local excision of the breast lesion revealed a 1.6 × 1.0 cm, estrogen and progesterone receptors strongly positive (>90% of cells) and Her2/neu negative, Nottingham histologic grade 2 invasive duct carcinoma with positive superior margin. Dissection of axillary area revealed 4 sentinel lymph nodes; however, blue dye was picked up by 2 sentinel nodes only. The background radioactivity, after removal of 4 sentinel lymph nodes, was 73 and 27.
Gross Description of the Sentinel Lymph Nodes Sentinel node 1 (hot and blue, count 5708) measured 1.5 × 1.0 × 0.5 cm. The hot and blue node 2 (count 883) and hot and nonblue sentinel node 3 (count 445) measured 1.5 × 1.0 × 0.8 cm and 1.5 × 1.0 × 0.5 cm. respectively. Sentinel node 4 (hot and nonblue, count 1069) measured 2.5 × 2.0 × 0.5 cm. No tumor was identified on gross examination in any of the nodes. The nodes were entirely submitted for microscopic examination, following the routine sentinel lymph node processing protocol used at our institution. Briefly, the sentinel lymph nodes are handled as follows: Nodes are put through in toto, bisected or trisected, depending on the size, and each portion is put in a separate green cassette. Levels 1, 3, and 5 are stained for routine hematoxylin and eosin stains and the unstained slides are kept for special stains if required. Grossly positive nodes are processed as regular lymph nodes.
Microscopic Findings Sentinel nodes 2 and 3 showed somewhat similar microscopic features. The capsules of both the lymph nodes, in multiple foci, were studded with densely packed elongated cells. Some of these clearly showed long dendritic processes. These cells contained fine granular brown pigments. However, coarse pigments were also present. In addition to the elongated dendritic cells, histiocytes with coarse pigments were also noted, mimicking hemosiderin laden macrophages. The blue nevus was present in continuation with the benign nevus cells giving an impression that blue nevus is arising from the benign nevus cells (Figure 1A and B) in sentinel node 2. The dendritic cells were cytologically benign and better viewed toward the edge of the lesion (Figure 1B). No mitotic figures were noted. The blue nevus extended inside the node along the trabeculae (Figure 1A, inset). On S-100 immunohostochemical stain, rare clusters of blue nevus cells were also detected within the parenchyma of the node (Figure 1C).
The nevus cells were also strongly reactive to Melan A. The HMB-45 immunohistochemical stain show positive staining in the blue nevus (Figure 1D). A proliferative index marker (Ki67) was done and only scattered positive nuclei were noted in the nodal blue nevus (Figure 1E). A Perls’ iron stain was completely negative (Figure 1F) although some of the granules apparently were coarse and appeared to be hemosiderin on hematoxylin and eosin stain. Node 3 with blue nevus also showed multiple foci of blue nevi in the capsule and in the trabeculae. However, no benign nevus cells were noted. No metastatic tumor was seen in these 2 sentinel nodes. Sentinel node 1 showed micrometastatic carcinoma with extracapsular extension (Figure 1G). Sentinel lymph node 4 was benign, and showed neither metastatic tumor nor blue nevus. The patient subsequently underwent additional surgery for her positive superior margin and no residual tumor was present in the re-excised specimen. Axillary dissection was not recommended as she had only micrometastasis in 1 sentinel lymph node. Adjuvant radiation therapy, chemotherapy, and endocrine therapy was recommended for the clinical management of the patient.
Discussion The current report is noteworthy as more than one sentinel lymph nodes revealed blue nevus with involvement of both capsule and nodal parenchyma. In addition, blue nevus was seen contiguous to benign nevus cells and giving an appearance that it was arising from benign nevus cells. Combined blue nevus and benign nevus cells in the same node have not been reported in the literature previously. Pigmented lesion in the lymph node should raise suspicion of a metastatic melanocytic lesion. The morphology of the tumor cells should be carefully evaluated. In addition, immunohistochemical staining may play a role to rule out a metastatic lesion. Ki67 proliferative index marker has been reported to be useful in clinical practice.10 In our, case the proliferative index maker (Ki67) is only sparsely positive supporting a benign lesion. Although use of HMB-45 has been proposed by some authors as a helpful marker to differentiate nodal nevi from melanoma,10 nodal nevi can be positive for HMB-45, as in our current case. Reticulin stain also has been reported to show differential staining patterns in melanoma and benign nevus cases; that is, in melanoma, reticulin surrounds nests of cells while in benign nevus individual cells are surrounded by reticulin.11 We did not attempt reticulin stain in our case as the benign nevus cells and the cells of the blue nevi did not show any cytologic atypia or mitosis. In addition, prominent nuclei, seen in melanoma were also absent here. Moreover, no clinical history of malignant melanoma or
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
572
International Journal of Surgical Pathology 22(6)
Figure 1. (A) Hematoxylin and eosin (H&E) stain with benign nevus cells and bleu nevus in the capsule of a sentinel lymph node. Inset: blue nevus extending inside node traveling along the trabeculae. (B) H&E: Higher magnification of (A). (C) S-100 immunohistochemistry shows positive immunoreactivity to the nevus cells; also highlights rare clusters of nevus cells in the parenchyma of the node. (D) HMB-45 shows positive immunoreactivity to the blue nevus cells. (E) Ki67 proliferative index marker shows scattered positivity to the nevus cells. (F) Perls’ iron stain: The granules are negative for iron stain. (G) H&E: Micrometastasis with extracapsular extension in the third sentinel lymph node.
pigmented skin lesion was present in this patient. As a result, the differential diagnosis of metastatic melanoma was ruled out. The histogenesis of the nevus cell in lymph nodes is disputed. Benign “metastatic” cellular blue nevus has been reported.5 However, most authors favor a melanocyte migration arrest to be the histogenetic mechanism rather than the hypothesis of a “benign metastasis” from a cutaneous site.4,12 Presence of blue nevus or benign nevus cells in axillary sentinel node has no impact in patient management. However, it may pose a challenge for pathologist during intraoperative evaluation of sentinel node in patient with breast carcinoma, as these cells, especially the nevus cells, may mimic metastatic tumor on touch preparation. Being aware of the existence of such entity may guide the
pathologist not to overcall the lesion during intraoperative evaluation, which may lead to unnecessary surgery. Routine immunohistochemical stains are probably not necessary in diagnosing blue nevus and benign nevus cells in the lymph node. However, in the presence of a history of pigmented skin lesion, immunohistochemical and reticulin stains are recommended. In addition, careful morphologic evaluation and comparison with the original pigmented lesion, if any, should always be pursued. Special stains, however, are recommended in community practice setting where breast cancer cases are not dealt with on a daily basis. Pathologists in any academic medical center or large private medical institute with a breast health center would be familiar with benign nevus cells and blue nevus in axillary lymph nodes. Granted that the blue nevus is much less common than benign nevus cells, the characteristic
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
573
Begum et al features of blue nevi, in any location, are unmistakable and their presence in various organs in the body is well documented. The intensely pigmented bipolar and dendritic nevus cells are characteristics of blue nevus and different from metastatic carcinoma or malignant melanoma cells. Attention to the details of the morphologic appearance of the tumor cells is always rewarding. Intraoperative evaluation of sentinel lymph nodes, a common practice during breast surgical procedure, can be tricky in the presence of a blue nevus or benign nevus cells in the nodal capsule or trabeculae of the capsule. The pathologists need to be aware of the condition to avoid overdiagnosis, which may lead to overtreatment or unnecessary treatment. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Stewart FW, Copeland MM. Neurogenic sarcoma. Am J Cancer. 1931;15:1235-1320. 2. Biddle DA, Evans HL, Kemp BL, et al. Intraprenchymal nevus cell aggregates in lymph nodes: a possible diagnostic
pitfall with malignant melanoma and carcinoma. Am J Surg Pathol. 2003;27:673-681. 3. Epstein JI, Erlandson RA, Rosen PP. Nodal blue nevi: a study of three cases. Am J Surg Pathol. 1984;8:907-914. 4. Azzopardi JG, Ross CM, Frizzera G. Blue nevi of the lymph node capsule. Histopathology. 1977;1:451-461. 5. Lambert WC, Brodkin RH. Nodal and subcutaneous cellular blue nevi. A pseudometastasizing pesudomelanoma. Arch Dermatol. 1984;120:367-370. 6. Bautista NC, Cohen S, Anders KH. Benign melanocytic nevus cells in axillary lymph nodes. A prospective incidence and immunohistochemical study with literature review. Am J Clin Pathol. 1994;102:102-108. 7. McCarthy SW, Palmer AA, Bale PM, Hirst E. Nevus cells in lymph nodes. Pathology. 1974;6:351-358. 8. Ridolfi RL, Rosen PP, Thaler H. Nevus cell aggregates associated with lymph nodes: estimated frequency and clinical significance. Cancer. 1977;39:164-171. 9. Carson KF, Wen DR, Li PX, et al. Nodal nevi and cutaneous melanomas. Am J Surg Pathol. 1996;20:834-840. 10. Lohmann CM, Iverson K, Jungbluth AA, Berwick M, Busam KJ. Expression of melanocyte differentiation antigens and Ki-67 in nodal nevi and comparison of Ki67 expression with metastatic melanoma. Am J Surg Pathol. 2002;26: 1351-1357. 11. Kanner WA, Barry CI, Smart CN, Frishberg DP, Binder SW, Wick MR. Reticulin and NM23 staining in the interpretation of lymph nodal nevus rests. Am J Dermatol. 2013;35: 452-457. 12. Mancini L, Gubinelli M, Fortunato C, Carella R. Blue nevus of the lymph node capsule. Report of a case. Pathologica. 1992;84:547-550.
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
research-article2013
IJSXXX10.1177/1066896913509008International Journal of Surgical PathologyBegum et al
Case Report
Nodal Combined Blue Nevus and Benign Nevus Cells in Multiple Axillary Sentinel Nodes in a Patient With Breast Carcinoma: Report of a Case
International Journal of Surgical Pathology 2014, Vol. 22(6) 570–573 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896913509008 ijs.sagepub.com
S. M. K. Nahar Begum, MBBS, MPhil1, Michele Lomme, MD1, and M. Ruhul Quddus, MD, MPhil1
Abstract Combined blue nevus and benign nevus cells were identified in the same sentinel lymph node. Blue nevus alone was also present in an additional sentinel lymph node in the same axilla in a patient who underwent needle localization, wide local excision, and sentinel lymph node biopsy for her pT1cN1mi(sn)M(na) invasive duct carcinoma of the breast. Of the 4 sentinel lymph nodes, 1 showed micrometastasis and 2 other lymph nodes showed blue nevus involving the capsule and trabeculae of the nodes. The patient had no significant previous clinical history of any skin tumors and had a negative clinical examination for malignant melanoma or pigmented skin lesions after the diagnosis of nodal blue nevus. To our knowledge, this is the first case report of combined blue nevi involving multiple sentinel lymph nodes in the same axilla. An equally interesting finding is the presence of benign nonpigmented nevus cells in continuation with the blue nevus in the same node. Keywords nodal combined blue nevus, benign nevus cells, sentinel node, breast cancer
Introduction
Case Report
The report of benign nevus cells, in the hilar connective tissue of axillary lymph node, was published by Stewart and Copeland1 in 1931. It is also well documented that benign nevus cells are found within the capsule and trabeculae of axillary lymph nodes.2 Biddle et al2 also reported intraparenchymal nevus cell aggregates in lymph nodes. Epstein et al3 reported 3 cases of blue nevus and documented that only 1 lymph node in each axilla was involved by blue nevus. Azzopardi et al4 were the first to report blue nevus in the capsule and fibrous trabeculae of the lymph nodes and 1 of the 2 cases reported had an ordinary blue nevus in the skin. Lambert and Brodkin5 also reported a cellular blue nevus in inguinal lymph node of a 20-year-old white woman, which was initially thought to be “metastatic melanoma” and the patient was subject to unnecessary surgery. The report of Lambert and Brodkin emphasizes the importance of correctly recognizing the blue nevus in lymph nodes and not to overdiagnose the lesion as metastatic disease. The incidence of benign nevus cells varies from 0.33% to 7.3% in cases other than melanoma6-8 and as high as 22% in cases of malignant melanoma.9
A 53-year-old, gravid 4 para 2 white woman presented with an abnormal mammogram showing architectural distortion in her right breast and a hypoechoic spiculated mass at 9 o’clock. On examination, the breasts are symmetrical, soft, and nontender. Manual examination did not reveal any palpable breast mass and no palpable axillary lymph nodes were detected. The patient had no significant previous clinical history of any skin tumors and negative clinical examination for malignant melanoma or any pigmented of the skin after the nodal combined blue nevus was detected in axillary sentinel lymph node. Her menarche was at age 14 and had a vaginal hysterectomy 6 years ago because of benign disease. The ovaries 1
Warren Alpert Medical School of Brown University, Providence, RI, USA Corresponding Author: M. Ruhul Quddus, Department of Pathology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI 02905, USA. Email: [email protected]
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
571
Begum et al were not removed. Two paternal aunts had breast cancer diagnosed in their 70s; both of them are alive and well at 88 and 76 years of age with no evidence of diseases. Wide local excision of the breast lesion revealed a 1.6 × 1.0 cm, estrogen and progesterone receptors strongly positive (>90% of cells) and Her2/neu negative, Nottingham histologic grade 2 invasive duct carcinoma with positive superior margin. Dissection of axillary area revealed 4 sentinel lymph nodes; however, blue dye was picked up by 2 sentinel nodes only. The background radioactivity, after removal of 4 sentinel lymph nodes, was 73 and 27.
Gross Description of the Sentinel Lymph Nodes Sentinel node 1 (hot and blue, count 5708) measured 1.5 × 1.0 × 0.5 cm. The hot and blue node 2 (count 883) and hot and nonblue sentinel node 3 (count 445) measured 1.5 × 1.0 × 0.8 cm and 1.5 × 1.0 × 0.5 cm. respectively. Sentinel node 4 (hot and nonblue, count 1069) measured 2.5 × 2.0 × 0.5 cm. No tumor was identified on gross examination in any of the nodes. The nodes were entirely submitted for microscopic examination, following the routine sentinel lymph node processing protocol used at our institution. Briefly, the sentinel lymph nodes are handled as follows: Nodes are put through in toto, bisected or trisected, depending on the size, and each portion is put in a separate green cassette. Levels 1, 3, and 5 are stained for routine hematoxylin and eosin stains and the unstained slides are kept for special stains if required. Grossly positive nodes are processed as regular lymph nodes.
Microscopic Findings Sentinel nodes 2 and 3 showed somewhat similar microscopic features. The capsules of both the lymph nodes, in multiple foci, were studded with densely packed elongated cells. Some of these clearly showed long dendritic processes. These cells contained fine granular brown pigments. However, coarse pigments were also present. In addition to the elongated dendritic cells, histiocytes with coarse pigments were also noted, mimicking hemosiderin laden macrophages. The blue nevus was present in continuation with the benign nevus cells giving an impression that blue nevus is arising from the benign nevus cells (Figure 1A and B) in sentinel node 2. The dendritic cells were cytologically benign and better viewed toward the edge of the lesion (Figure 1B). No mitotic figures were noted. The blue nevus extended inside the node along the trabeculae (Figure 1A, inset). On S-100 immunohostochemical stain, rare clusters of blue nevus cells were also detected within the parenchyma of the node (Figure 1C).
The nevus cells were also strongly reactive to Melan A. The HMB-45 immunohistochemical stain show positive staining in the blue nevus (Figure 1D). A proliferative index marker (Ki67) was done and only scattered positive nuclei were noted in the nodal blue nevus (Figure 1E). A Perls’ iron stain was completely negative (Figure 1F) although some of the granules apparently were coarse and appeared to be hemosiderin on hematoxylin and eosin stain. Node 3 with blue nevus also showed multiple foci of blue nevi in the capsule and in the trabeculae. However, no benign nevus cells were noted. No metastatic tumor was seen in these 2 sentinel nodes. Sentinel node 1 showed micrometastatic carcinoma with extracapsular extension (Figure 1G). Sentinel lymph node 4 was benign, and showed neither metastatic tumor nor blue nevus. The patient subsequently underwent additional surgery for her positive superior margin and no residual tumor was present in the re-excised specimen. Axillary dissection was not recommended as she had only micrometastasis in 1 sentinel lymph node. Adjuvant radiation therapy, chemotherapy, and endocrine therapy was recommended for the clinical management of the patient.
Discussion The current report is noteworthy as more than one sentinel lymph nodes revealed blue nevus with involvement of both capsule and nodal parenchyma. In addition, blue nevus was seen contiguous to benign nevus cells and giving an appearance that it was arising from benign nevus cells. Combined blue nevus and benign nevus cells in the same node have not been reported in the literature previously. Pigmented lesion in the lymph node should raise suspicion of a metastatic melanocytic lesion. The morphology of the tumor cells should be carefully evaluated. In addition, immunohistochemical staining may play a role to rule out a metastatic lesion. Ki67 proliferative index marker has been reported to be useful in clinical practice.10 In our, case the proliferative index maker (Ki67) is only sparsely positive supporting a benign lesion. Although use of HMB-45 has been proposed by some authors as a helpful marker to differentiate nodal nevi from melanoma,10 nodal nevi can be positive for HMB-45, as in our current case. Reticulin stain also has been reported to show differential staining patterns in melanoma and benign nevus cases; that is, in melanoma, reticulin surrounds nests of cells while in benign nevus individual cells are surrounded by reticulin.11 We did not attempt reticulin stain in our case as the benign nevus cells and the cells of the blue nevi did not show any cytologic atypia or mitosis. In addition, prominent nuclei, seen in melanoma were also absent here. Moreover, no clinical history of malignant melanoma or
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
572
International Journal of Surgical Pathology 22(6)
Figure 1. (A) Hematoxylin and eosin (H&E) stain with benign nevus cells and bleu nevus in the capsule of a sentinel lymph node. Inset: blue nevus extending inside node traveling along the trabeculae. (B) H&E: Higher magnification of (A). (C) S-100 immunohistochemistry shows positive immunoreactivity to the nevus cells; also highlights rare clusters of nevus cells in the parenchyma of the node. (D) HMB-45 shows positive immunoreactivity to the blue nevus cells. (E) Ki67 proliferative index marker shows scattered positivity to the nevus cells. (F) Perls’ iron stain: The granules are negative for iron stain. (G) H&E: Micrometastasis with extracapsular extension in the third sentinel lymph node.
pigmented skin lesion was present in this patient. As a result, the differential diagnosis of metastatic melanoma was ruled out. The histogenesis of the nevus cell in lymph nodes is disputed. Benign “metastatic” cellular blue nevus has been reported.5 However, most authors favor a melanocyte migration arrest to be the histogenetic mechanism rather than the hypothesis of a “benign metastasis” from a cutaneous site.4,12 Presence of blue nevus or benign nevus cells in axillary sentinel node has no impact in patient management. However, it may pose a challenge for pathologist during intraoperative evaluation of sentinel node in patient with breast carcinoma, as these cells, especially the nevus cells, may mimic metastatic tumor on touch preparation. Being aware of the existence of such entity may guide the
pathologist not to overcall the lesion during intraoperative evaluation, which may lead to unnecessary surgery. Routine immunohistochemical stains are probably not necessary in diagnosing blue nevus and benign nevus cells in the lymph node. However, in the presence of a history of pigmented skin lesion, immunohistochemical and reticulin stains are recommended. In addition, careful morphologic evaluation and comparison with the original pigmented lesion, if any, should always be pursued. Special stains, however, are recommended in community practice setting where breast cancer cases are not dealt with on a daily basis. Pathologists in any academic medical center or large private medical institute with a breast health center would be familiar with benign nevus cells and blue nevus in axillary lymph nodes. Granted that the blue nevus is much less common than benign nevus cells, the characteristic
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
573
Begum et al features of blue nevi, in any location, are unmistakable and their presence in various organs in the body is well documented. The intensely pigmented bipolar and dendritic nevus cells are characteristics of blue nevus and different from metastatic carcinoma or malignant melanoma cells. Attention to the details of the morphologic appearance of the tumor cells is always rewarding. Intraoperative evaluation of sentinel lymph nodes, a common practice during breast surgical procedure, can be tricky in the presence of a blue nevus or benign nevus cells in the nodal capsule or trabeculae of the capsule. The pathologists need to be aware of the condition to avoid overdiagnosis, which may lead to overtreatment or unnecessary treatment. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Stewart FW, Copeland MM. Neurogenic sarcoma. Am J Cancer. 1931;15:1235-1320. 2. Biddle DA, Evans HL, Kemp BL, et al. Intraprenchymal nevus cell aggregates in lymph nodes: a possible diagnostic
pitfall with malignant melanoma and carcinoma. Am J Surg Pathol. 2003;27:673-681. 3. Epstein JI, Erlandson RA, Rosen PP. Nodal blue nevi: a study of three cases. Am J Surg Pathol. 1984;8:907-914. 4. Azzopardi JG, Ross CM, Frizzera G. Blue nevi of the lymph node capsule. Histopathology. 1977;1:451-461. 5. Lambert WC, Brodkin RH. Nodal and subcutaneous cellular blue nevi. A pseudometastasizing pesudomelanoma. Arch Dermatol. 1984;120:367-370. 6. Bautista NC, Cohen S, Anders KH. Benign melanocytic nevus cells in axillary lymph nodes. A prospective incidence and immunohistochemical study with literature review. Am J Clin Pathol. 1994;102:102-108. 7. McCarthy SW, Palmer AA, Bale PM, Hirst E. Nevus cells in lymph nodes. Pathology. 1974;6:351-358. 8. Ridolfi RL, Rosen PP, Thaler H. Nevus cell aggregates associated with lymph nodes: estimated frequency and clinical significance. Cancer. 1977;39:164-171. 9. Carson KF, Wen DR, Li PX, et al. Nodal nevi and cutaneous melanomas. Am J Surg Pathol. 1996;20:834-840. 10. Lohmann CM, Iverson K, Jungbluth AA, Berwick M, Busam KJ. Expression of melanocyte differentiation antigens and Ki-67 in nodal nevi and comparison of Ki67 expression with metastatic melanoma. Am J Surg Pathol. 2002;26: 1351-1357. 11. Kanner WA, Barry CI, Smart CN, Frishberg DP, Binder SW, Wick MR. Reticulin and NM23 staining in the interpretation of lymph nodal nevus rests. Am J Dermatol. 2013;35: 452-457. 12. Mancini L, Gubinelli M, Fortunato C, Carella R. Blue nevus of the lymph node capsule. Report of a case. Pathologica. 1992;84:547-550.
Downloaded from ijs.sagepub.com at UNIVERSITE DE MONTREAL on June 10, 2015
