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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 2  |  Page : 96-100

Spectrum of diseases in the axilla: A histopathological analysis of axillary masses


1 Department of Morbid Anatomy and Forensic Medicine, College of Health Sciences, Usmanu Danfodio University, Sokoto, Nigeria
2 Department of Pathology, Ahmadu Bello University and Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria

Date of Web Publication5-Oct-2017

Correspondence Address:
Usman Bello
Department of Morbid Anatomy and Forensic Medicine, College of Health Sciences, Usmanu Danfodio University, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_32_16

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  Abstract 

Background: This is an analysis of axillary masses to determine the spectrum of diseases that are commonly encountered in the axilla. Materials and Methods: Ten years' consecutive analysis axillary biopsies sent to the pathology laboratory of a tertiary hospital were formalin fixed, paraffin embedded, and stained with hematoxylin and eosin (H and E). Stains such as Ziehl–Neelsen, vermentin and CD5, CD20, and CD23 were also employed in further differentiation of diseases. Results: Fifty-nine axillary lesions were analyzed from 21 males and 38 females. The ages ranged from 2 months to 80 years and peaked in the third decade of life. There were eight developmental (congenital) lesions (13.6%), seven infectious (12.0%), 12 reactive (20.3%), and 31 neoplastic lesions (52.5%). All the congenital lesions were aberrant breast tissues. There were 19 non-neoplastic lymph nodes and 12 of them (63.2%) were reactive hyperplasia remaining (35%) being granulomatous inflammations of which four were tuberculous. A case of hematoma in a 2-month-old male child was seen. The neoplastic diseases were dominated by lipoma; five cases (16.1%), non-Hodgkin's lymphoma; 11 cases (35.5%), and metastatic carcinoma; 5 cases (16.1%). Conclusion: The most common tissue of affectation in the axilla was the lymph node. Malignant neoplastic diseases were the commonest pathology with female predisposition; the peak age of presentation was the third decade of life was the third decade. Histologic evaluation of axillary masses will aid in the prompt and appropriate treatment of diseases to reduce attendant morbidity and mortality.

Keywords: Axilla, accessory breast tissue, lymph nodes, lipoma


How to cite this article:
Bello U, Omotara SM. Spectrum of diseases in the axilla: A histopathological analysis of axillary masses. Niger J Basic Clin Sci 2017;14:96-100

How to cite this URL:
Bello U, Omotara SM. Spectrum of diseases in the axilla: A histopathological analysis of axillary masses. Niger J Basic Clin Sci [serial online] 2017 [cited 2019 Jul 19];14:96-100. Available from: http://www.njbcs.net/text.asp?2017/14/2/96/216049


  Introduction Top


The components of the axilla can give rise to different diseases ranging from developmental and reactive to neoplastic. These diseases can arise de novo as primary lesions or be secondary diseases from distant sites. The often-encountered congenital lesions are the aberrant breast tissues which are also subject to same disorders of the breast such as mastitis, lactational changes, phyllodes tumor, fibrocystic changes, fibroadenoma, and cancers located at usual anatomical sites.[1],[2],[3],[4] Other congenital disorders that may be located in the axilla include cystic hygroma [5],[6] Soft tissue tumors are uncommon in the axilla and there have been reports of lipoma, schwannoma, and dermatofibroma including their malignant counterparts.[7],[8],[9] Other reported diseases are skin adnexal tumors and extraskeletal chondroma.[10],[11],[12]

Axillary group of lymph nodes also respond to varied assaults ranging from microbial infections, infestations to neoplastic diseases.[13] In tropical countries, such microbial infections and infestations include hydatid disease and sparganosis an extremely rare disease caused by the migrating procercoid larvae of Diphyllobothrium mansoni.[14],[15] Though, secondary tumors are more common.[16]


  Materials and Methods Top


This is a 10-year analysis of all axillary biopsies submitted to the Department of Pathology, Ahmadu Bello University Teaching Hospital (ABUTH) Shika-Zaria, from 1 January 2006 to 31 December 2015. All relevant tissue slides stained with hematoxylin and eosin (H and E) were retrieved and studied. Fresh slides were made from stored paraffin embedded tissue blocks where needed. In addition to H and E stain, Ziehl–Neelsen, periodic acid-Schiff, and silver stains were used in cases of granulomatous inflammation while all cases of lymphoma and other malignant lesions were characterized with immunohistochemical stains such as CD3, CD5, CD15, CD20, CD23, vimentin, pancytokeratin (AE1/AE3), and S100. Patient's clinical information including age and sex were extracted from the accompanying case cards.


  Results Top


Seventy-four surgical biopsy specimens were received during the study period. Fifty-nine of these fulfilled the study criteria; that is isolated cases of axillary masses, 10 biopsies were done in patient with breast cancers and were excluded from the study. The remaining cases had either missing information and/or histopathologic materials.

There were 59 different pathologic lesions recorded during the study period with 21 male and 38 females and a male to female ratio of 1:1.8. Their ages ranged from 2 months to 80 years and peaked in the third decade of life [Table 1].
Table 1: Sex distribution of the various disorders diagnosed during the study period

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The diseases were categorized into developmental (congenital); eight lesions (13.6%), reactive; 12 lesions (20.3%), infectious; seven lesions (12.0%), and neoplastic; 31 lesions (52.5%) [Table 2]. Overall the most common group of lesions were neoplastic diseases comprising 52.5% of the cases.
Table 2: Age distribution of the various diagnoses during the study

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All the congenital lesions seen in this study were accessory breast tissues. Two of these aberrant breast tissues were unremarkable; however, three cases were affected each by invasive ductal carcinoma and fibrocystic change, respectively [Table 3].
Table 3: Clinicopathologic characteristics of the developmental lesions

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Infectious/reactive lesions were the second most common of the pathologic lesions encountered in this study. Majority of these (60.0%) were reactive hyperplastic lymph nodes enlargement believed to be secondary to locoregional ongoing disease processes which were not unraveled. There were seven cases of granulomatous inflammations, four of which were tuberculous while the other three the morphologic features were nonspecific and etiologic agent was not identified even with special stains and were therefore referred to as chronic nonspecific granulomatous inflammations. A case of hematoma in a 2-month-old male child was also recorded.

Neoplastic diseases both benign and malignant were the most common lesions seen in this report. As shown in [Figure 1], lipoma is the commonest among benign cases. Other benign tumors seen are epidermoid cyst, dermoid cyst, and neurofibroma. Altogether, benign tumors formed 13.6% of the entire report, but constitutes 25.8% of the neoplastic diseases. The malignant diseases constitute 74.2% of the neoplastic diseases seen in this report. Primary tumors are, non-Hodgkin's lymphoma; 11 (35.5%), squamous cell carcinoma; 2 (6.5%), and one case each of sebaceous carcinoma, fibrosarcoma, liposarcoma, malignant peripheral nerve sheath tumor, and an alveolar rhabdomyosarcoma seen in a 7-year-old female child.
Figure 1: Line graph showing the distribution of various neoplastic disorders during the study period

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Among the 11 cases of non-Hodgkin's lymphoma seven cases were diffuse large B-cell lymphoma, one case of small lymphocytic lymphoma, two cases of lymphoblastic lymphoma, and a case of Burkitt's lymphoma. Their ages ranged from 5 years to 60 years and peaked at the sixth decade of life [Table 1]. Five cases (16.1%) were metastatic carcinoma whose primaries were later found from the nasopharynx (2), lungs (1), thyroid (1), and esophagus (1).


  Discussion Top


Primary disorders presenting as axillary masses are not uncommon and as shown in this report include wide range of diseases from congenital aberrant breast tissues (13.6%) through infectious/reactive processes (20.3%) to indolent neoplasm like lipoma (8.5%), and highly malignant tumors such as rhabdomyosarcoma. Overall neoplastic diseases were the most common accounting to 52.5% of our biopsies. De Andrade et al.,[17] in a similar study reported comparable range of pathologies in their 31 patients with axillary masses. In their series the most common disorder was a metastatic occult breast cancer, while accessory breast tissue formed 16.1%.[17]

The developmental lesions seen in our report were all aberrant breast tissues. Accessory breast tissue can develop all the pathological lesions developed by the anatomically developed breast. In the index report, three of our cases were affected with invasive ductal carcinoma; the most common malignant tumors of the breast. Malignant tumors are the most common diseases affecting the accessory breast tissues; Badejo reported that, the incidence of malignant changes in accessory breast tissue was 14%.[18] Invasive ductal carcinoma is the most frequently reported malignant change in this aberrant tissues.[2],[19],[20],[21],[22] Three cases show fibrocystic change, a benign lesion affecting young to middle-aged female. Similarly in Brazil, De Andrade reported three cases of fibrocystic change among their five cases of accessory breast tissues with two others having fibroadenoma.[17] Fibrocystic change is less common than malignant tumors particularly carcinoma in aberrant breast tissue.[3] Approximately 1% to 5% of men and women have aberrant accessory breast. Most cases are sporadic, but about 6% are familial and are believed to represent an autosomal dominant trait with variable penetrance.[1] Though the only congenital lesions seen in this study was accessory breasts, Guner et al. reported two cases of axillary cystic hygroma in adult while Manikoth et al. reported an axillary cystic hygroma diagnosed in utero.[5],[6] Most cases of cystic hygromas (80%) occur in the neck, usually in the posterior cervical triangle, less frequently other sites can be affected including the axilla, superior mediastinum, mesentery, retroperitoneal region, pelvis, and lower limbs. Cystic hygromas may be associated with some congenital syndromes and anomalies like Turner syndrome, Noonan syndrome, trisomies, cardiac anomalies, and fetal hydrops.[23]

Neoplastic diseases were the most common lesion comprising 52.5% of the entire series. Eight cases were benign tumors; six mesenchymal tumors of which five were conventional lipoma and one neurofibroma while the other two were epithelial cystic lesions; an epidermal cyst and dermoid cyst. Lipoma is the most common of the mesenchymal tumors affecting many parts of the body with few exceptional cases reported in the axilla.[24],[25] Neurofibroma and other peripheral nerve tumors less frequently present in the axillary area. Idil et al., in Turkey and Jadhav et al. in India each reported a case of axillary schwannoma.[26],[27] Epidermal inclusion cysts are usually post traumatic tumor-like conditions and in such conditions malignancy should be ruled out histologically. Zhang et al. reported a rapidly enlarging squamous inclusion cyst following core needle biopsy in the axilla.[28]

The malignant counterparts however outnumbered the benign tumors; 74.2% of the neoplastic lesions were malignant and non-Hodgkin's lymphoma formed bulk of these tumors (47.8%). Diffuse large B-cell lymphoma was the most common of the malignant tumors in this study. Similar to our findings, Ribas et al. reported that diffuse large B-cell lymphoma is the most common non-Hodgkin's lymphoma accounting to 30% of cases.[13] Other malignant tumor recorded in this report were epithelial cancers arising from the skin and skin adnexa; squamous cell carcinoma and sebaceous carcinoma. Agrawal et al. reported a case of apocrine adenocarcinoma in the axilla of a young man.[29] Carcinoma arising from the skin and adnexa are usually commoner in the exposed skin surfaces and associated in some cases with human papilloma viral infection, but the axilla is an uncommon site.

Malignant soft tissue tumors are relatively common, but presentation in the axilla is uncommon. We have recorded a case each of fibrosarcoma, liposarcoma, rhabdomyosarcoma, and malignant peripheral nerve sheath tumor. These are tumors presenting as deep soft tissue malignancy of the abdomen and extremities. According to Kim et al. primary malignant soft tissue tumor are rare in the axilla but may occur,[9] these tumors are unlikely to differentiate toward any line of origin; the commonest being malignant fibrous histiocytoma. All our cases follow their histogenic line of differentiation morphologically.

Metastatic carcinoma from unknown primaries to the axillary groups of lymph nodes is not uncommon, with the commonest primaries being carcinoma of the breast. However, other malignant tumors can also be received as metastatic deposits. We recorded five cases of metastatic carcinoma from nasopharynx, lung, thyroid, and esophagus. Carcinoma from any of the locoregional organs are common; however, some nonregional distant metastasis were also not uncommon. Anne et al. reported a metastatic melanoma from the eye to the axilla of a 51-year-old female.[30]

Lymphadenopathy secondary to locoregional reaction seldom require surgical evaluation because most cases resolve spontaneously; however, persistent cases may need tissue evaluations. We recorded 12 cases of nonspecific reactive hyperplastic axillary adenopathy and 7 cases of granulomatous inflammations. Four of these show typical caseous granuloma with characteristic acid fast bacilli. Tuberculosis is quite common in this environment, but the typical tuberculous adenitis which is the most common form of extra pulmonary tuberculosis; usually involve cervical group of lymph nodes (scrofula).[31]

Infectious granulomatous lymphadenitis whether suppurative or nonsuppurative can affect one or more group of lymph nodes; including axillary group of lymph nodes. Suppurative diseases like tularemia, cat scratch disease, Yersinia infection, and lymphogranuloma venereum may present with lymphadenitis; however, tularemia and cat scratch disease are apt to affect the axillary regions.[32] The nonsuppurative granulomatous lymphadenitis are usually caused by fungal infection, tuberculosis or following vaccination with Bacillus Calmette-Guérin (BCG) especially in children; these commonly affect cervical lymph nodes with few reported cases affecting axillary group of lymph nodes.[31],[32]

In conclusion, the most common tissue of affectation in the axilla was the lymph node. Malignant neoplastic diseases were the commonest with a female predisposition and peak age of presentation was the third decade of life. Histologic evaluation of axillary masses will aid in the prompt and appropriate treatment of diseases to reduce attendant morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There authors declare no conflicts of interest.

 
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