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DOI: 10.5146/tjpath.2015.01334 |
Masson's Tumor Masquerading as a Papillary Adenocarcinoma on Fine Needle Aspiration Cytology: A Case Report |
Anita NANGIA, Shivali SEHGAL, Kiran AGARWAL |
Department of Pathology, Lady Hardinge Medical College, DELHI, INDIA |
Keywords: Masson's tumor, Papillary adenocarcinoma, Fine needle aspiration |
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Intravascular papillary endothelial hyperplasia, previously known as Masson's tumor, is a relatively uncommon reactive endothelial proliferation
that occurs most commonly in the vessels of the head, neck, and extremities. We report a case of intravascular papillary endothelial hyperplasia
in the neck in a 40-year-old female that was misdiagnosed as papillary adenocarcinoma on fine needle aspiration. The cytologic picture of
intravascular papillary endothelial hyperplasia is diverse, making a pinpoint diagnosis of this entity difficult on fine needle aspiration. |
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Intravascular papillary endothelial hyperplasia (IPEH),
previously known as ‘Masson's tumor, is a relatively
uncommon reactive endothelial proliferation that occurs
most commonly in the vessels of the head, neck, and
extremities. It has slight predilection for women and has
been reported in the age range of 9 months to 80 years 1.
The cytologic findings of the lesion are varied. We report a
case of IPEH in the neck that was initially misdiagnosed as a
papillary adenocarcinoma on fine needle aspiration (FNA ). |
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Abstract
Introduction
Case Presentation
Disscussion
References
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A 40-year-old female presented with a swelling in the
neck that was noticed 2 years ago and was progressively
increasing in size. It was a well defined, firm, mobile and
non tender swelling measuring 1.5 x 1 cm in the left upper
cervical region. The overlying skin was unremarkable. On
FNA , blood-mixed aspirate was obtained after which the
swelling partly reduced in size.
Smears were haemorrhagic showing cells lying singly, in
small nests, large clusters and in papillary fragments along
with presence of vascular tissue fragments (Figure 1).
Individual cells showed overlapping and were large with
moderate to abundant amount of cytoplasm with many
cells showing cytoplasmic vacuolisation. The nucleus was
central to eccentric, round to oval with moderate degree
of anisonucleosis, finely clumped chromatin and 1-2
prominent nucleoli (Figure 1, inset). There was a vague attempt to form acinar or papillaroid structures (Figure 2).
However, no intranuclear inclusions, psammoma bodies or
peripheral pallisading were seen in the smears examined.
Few mitotic figures were seen. The presence of pleomorphic
cells arranged in papillaroid and glandular patterns was
suspicious of metastatic papillary adenocarcinoma. The
patient was advised urgent excision. The section showed
numerous intravascular papillary structures along with
thrombosis at some foci (Figures 3, 4). The features were
suggestive of IPEH. Immunohistochemistry was done
and CD34 was found to be positive in the cells lining the
papillae, confirming their endothelial origin. CD34 was
also found to be positive in the adjacent fibrous stroma. A
final diagnosis of IPEH was made.
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Figure 1: Photomicrograph showing branching papillary
arrangement of cells (PAP; x100). Inset shows cells with nuclear
atypia (PAP; x400). |
Click Here to Zoom |
Figure 2: Photomicrograph showing cells arranged in vague
acinar pattern. Note the nuclear atypia of cells and an occasional
cell showing fine cytoplasmic vacuolisation (PAP; x400). |
Click Here to Zoom |
Figure 3: Photomicrograph showing numerous intravascular
papillary structures with thrombosis at some foci (H&E; x100). |
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Figure 4: Photomicrograph showing vascular lumen lined by
endothelial cells (H&E; x100). |
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Abstract
Introduction
Case Presentation
Disscussion
References
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IPEH is a benign neoplasm of endothelial cells that has been
well described in the surgical pathology literature. This
entity is now regarded as an exuberant form of organizing
thrombus rather than a true neoplasm 2. It can involve
an isolated dilated blood vessel or occur as a focal change
in preexisting vascular lesions such as hemangiomas and
varices, or rarely present in an extravascular location, in the
setting of a hematoma 2.
IPEH may be confused with a malignancy based on
FNA , particularly when the lesion occurs in uncommon
anatomic locations. There are only a few published reports
on aspiration cytology of IPEH. The markedly atypical appearance of aspirated endothelial cells, the absence
of specific features and the lack of cell block material for
morphological and immunohistochemical evaluation has
resulted in misdiagnosis of IPEH as a malignant neoplasm
on cytology aspirates in the past3-8.
Vascular tissue fragments should be differentiated from
granulomas and granulation tissue. Vascular fragments
are composed of cords and strands of spindle-shaped cells
(with blunt nuclei) representing capillary vessels separated
by connective tissue and are often found on a background
of profuse blood. Granulomas are cohesive clusters of
epithelioid cells, lymphocytes, plasma cells and giant cells.
Granulation tissue is composed of cohesive clusters of fibroblasts, histiocytes, inflammatory cells and capillary
vessels.
The cytological picture of IPEH is varied and thus the
differential diagnosis is challenging. The cases reported by
Novak et al. and Karim et al. were diagnosed as squamous
cell carcinomas on cytology due to the presence of dense
cytoplasm, hard cell borders, pleomorphic nuclei and
prominent, multiple nucleoli4,6. Suh et al. and Yoo-Duk
C et al. noted pleomorphic polygonal cells arranged in
alveolar or glandular clusters in the smears suggesting the
diagnosis of adenocarcinoma5,9. However, the former
case was diagnosed as metastatic embryonal carcinoma in
view of the patient's young age. Jain et al. noted cords and globular forms of hyaline material surrounded by plump
endothelial cells and interpreted them as diagnostic of
adenoid cystic carcinoma7. Garcia-Macias et al. reported
two distinct populations of cells in IPEH3. One type
had large nuclei, finely granular chromatin, prominent
nucleoli and abundant globular cytoplasm, with occasional
single cytoplasmic vacuoles. The second type of cells had
spindle to oval nuclei with granular chromatin and scanty
eosinophilic cytoplasm. This group identified correctly the
vascular nature of the cells, but considered it to be probably
malignant due to cellular atypia. Handa et al. reported a
IPEH on the wrist with presence of giant cells and spindle
cells on FNA smears which they interpreted as a giant cell
tumor10.
In conclusion, the cytologic features of IPEH are not
specific, which often result in diagnostic challenges.
However, it is important to suspect a vascular lesion when
atypical cells are found on a hemorrhagic background.
Furthermore, combination of cytologic features with
immunocytochemistry will aid in the correct diagnosis of
IPEH. |
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Abstract
Introduction
Case Presentation
Discussion
References
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1) Clearkin KP, Enzinger FM. Intravascular papillary endothelial
hyperplasia. Arch Pathol Lab Med. 1976;100:441-4.
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Intravascular papillary endothelial hyperplasia of the chest wall
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diagnosis of intravascular papillary endothelial hyperplasia: A
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2012;56:199-203. |
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Abstract
Introduction
Case Presentation
Discussion
References
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