Concurrent presence of primary hemangioma and breast cancer metastasis within a lymph node: a case report inspired by the legacy of Professor Juan Rosai

Abstract

Secondary neoplastic lesions in lymph nodes are predominantly metastases from solid tumors, whereas primary lymph node hemangiomas are exceptionally uncommon, with only 24 well-documented cases in the literature. Histologically, they are characterized by endothelial cells that may appear flattened or enlarged, with variable vascular density, and the presence of stromal elements. Notably, the concurrent presence of a primary hemangioma and a metastasis from breast cancer - the latter being the most prevalent secondary lesion in axillary lymph nodes - represents an unprecedented observation. The unique case presented herein underscores the exceptional rarity of primary lymph node hemangiomas and demonstrates for the first time their possible coexistence with breast cancer metastasis within the same axillary lymph node. In sharing and discussing this case study, we pay homage to Professor Juan Rosai, whose work in redefining rare and complex diagnoses continues to enlighten our understanding of lymph node vascular lesions.

Keywords: axillary lymph node; breast cancer; hemangioma; metastasis.

Figure 1.

Primary solitary hemangioma and breast cancer metastasis coexist in a single axillary lymph node. Representative micrographs showing the thin-walled capillary hemangioma (star) occupying approximately 50% of the lymph node parenchyma along with multiple metastatic deposits from breast cancer (arrows) and neoplastic emboli inside of non-neoplastic lymph vessels, as also demonstrated by cytokeratin staining (A, hematoxylin and eosin, original magnification, 50x; and insets, hematoxylin, and eosin and original magnification, pan-cytokeratin, 200x). At the immunohistochemical analysis, the lesion was positive for both CD31 (B, original magnification, 50x) and CD34 (C, original magnification, 50x), while D2-40 (aka podoplanin) was negative (D, original magnification, 50x).

Figure 2.

Captured moments of Juan Rosai (1940-2020) engaging with aspiring pathologists who participated in his weekly histological teaching sessions in Milan, Italy. The images feature three of the authors of this study (Nicola Fusco, Elena Guerini Rocco, and Fabio Pagni) during their tenure as pathology fellows, standing alongside the esteemed scholar. These photographs epitomize Juan Rosai’s dedication to nurturing the future generation of pathologists (Photographs taken in Milan, 2012 circa).