AJR 2000; 174:1060
© American Roentgen Ray Society
Radiologic-Pathologic Conferences
of Wake Forest University Baptist Medical Center |
Angiofollicular Lymphoid Hyperplasia (Castleman Disease) of the Axilla
Liem T. Bui-Mansfield1,
Felix S. Chew1 and
Cris P. Myers2
1
Department of Radiology, Wake Forest University School of Medicine, Medical
Center Blvd., Winston-Salem, NC 27157-1088
2
Department of Pathology, Walter Reed Army Medical Center, 6900 Georgia Ave. N.
W., Washington, DC 20307.
The opinions and assertions contained herein are those of the authors and
should not be construed as official or as representing the opinions of the
Department of the Army or the Department of Defense.
Address correspondence to F. S. Chew.
Introduction
A 37-year-old woman presented with a left axillary mass, suggestive of a
lymph node metastasis from a primary malignancy in the breast. Although
bilateral mammography showed a homogeneously dense axillary mass, no primary
lesion was detected. Sonography of the axilla showed an ovoid hypoechoic 3-cm
(maximum diameter) mass (Fig.
1A). The lesion contained hypoechoic tubular structures with blood
flow shown on color Doppler sonography
(Fig. 1B). Excisional biopsy
was performed. Microscopic sections of the enlarged lymph node showed numerous
small folliclelike structures with radially penetrating capillaries, some with
hyalinization in the central portion. A prominent vascular proliferation
filled the perifollicular tissue (Fig.
1C). A perifollicular concentric layering of small lymphocytes
("onion skinning") was noted on high-power magnification
(Fig. 1D). The final pathologic
diagnosis was angiofollicular lymphoid hyperplasia, hyaline vascular type
(Castleman disease).
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Fig. 1C. —37-year-old woman with angiofollicular lymphoid hyperplasia of
axilla. Photomicrograph of histopathologic specimen shows lymphoid follicles
surrounded by stroma that contain numerous hyperplastic capillaries, venules,
and arterioles. (H and E, low power)
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Fig. 1D. —37-year-old woman with angiofollicular lymphoid hyperplasia of
axilla. Photomicrograph of histopathologic specimen shows concentric layering
of follicular lymphocytes around hyalinized central vessel producing
characteristic "onion skin" pattern. (H and E, high power)
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Angiofollicular lymphoid hyperplasia is an unusual inflammatory condition
of unknown cause. It may be localized or generalized. Eighty-six percent of
lesions are found in the mediastinum or hilum, and 91% are of the hyaline
vascular type [1].
Histologically, hyaline vascular angiofollicular lymphoid hyperplasia is
characterized by multiple germinal centers separated by a polymorphous
lymphoreticular infiltrate containing numerous capillaries. It is usually
asymptomatic. Less common is a plasma cell type with fewer capillaries and
numerous plasma cells between the germinal centers. This variant often
produces systemic manifestations, including fever, anemia, weight loss, and
hypergammaglobulinemia. The prominent vascular proliferation characteristic of
angiofollicular lymphoid hyperplasia is not seen in healthy or reactive lymph
nodes and is also absent from lymph nodes involved with malignancy. The
vascular pattern present in hyaline vascular angiofollicular lymphoid
hyperplasia, when shown on color Doppler sonography, may help suggest the
specific diagnosis and help differentiate this benign process from nodal
metastases.
On CT, hyaline vascular angiofollicular lymphoid hyperplasia would appear
as a homogeneous mass with marked contrast enhancement. Angiography would show
a prominent tumor blush. MR imaging would show homogeneous architecture with
hypointensity on T1-weighted images and hyperintensity on T2-weighted images.
Sonography would show a hypoechoic mass with hyperechoic regions
[2], and color Doppler
sonography would show an artery penetrating the hilum of the mass and fine
accessory peripheral arteries
[3].
The differential diagnosis of an axillary mass in a woman includes
metastases; lymphoid neoplasms; and a number of reactive, inflamamtory, and
benign conditions. A homogeneously dense axillary mass evident on mammography
has a significant probability of being metastatic breast cancer, and
fine-needle aspiration or excisional biopsy of the mass should be considered
to establish a definitive diagnosis
[4].
References
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Walsh R, Kornguth PJ, Soo MS, Bentley R, DeLong DM. Axillary lymph
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AJR
1997;168: 33
-38[Abstract/Free Full Text]
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Introduction
References
