We present here a new case of the enlarged left axillary lymph node in a 42-year-old Bosnian female. She has got a pain in her left arm that has persisted for several weeks.  
On clinical examination, enlarged axillary lymph nodes were noticed. Two lymph nodes were surgically removed for diagnostic purposes.  
No other signs of the disease. Laboratory findings unremarkable.  
Gross examination revealed the presence two lymph nodes of which the first one measured 4x2.5 cm wheares the second one measured 2x1.5 cm.  
Microscopically, prominent thickening of the capsule of the lymph node was seen as well as a reactive, follicular hyperplasia. However, in several focuses within the lymphatic vessels, emboli of single, large cells with moderately abundant cytoplasm, large nuclei with prominent nucleoli were seen. These cells showed prominent pleomorphism and sporadic mitotic figures.  
Immunohistochemistry: Cytokeratin AE1-AE3 (negative), CK8 (negative), LCA (negative in the cells within the vessels), CD30 (positive), EMA (positive), S100 (negative), CD34 (positive, stains clearly the walls of the vessels).  
Clinical diagnosis: No  
Histopathological diagnosis: Reactive follicular hyperplasia of the lymph node with emboli of the tumor cells  
The origins of tumor cells: Anaplastic large cell lymphoma (ALCL), epitheloid sarcoma, metastatic carcinoma or?  
Please, give your opinions!

anpo 2007-10-22 21:48	If ALK-1 is clearly positive in tumor cells the diagnosis will be ALK-1 positive anaplastic large cell lymphoma. SOme of these have an angiocentric pattern and the tumor cells can be found as in this case - just around vessels.
tzankov 2007-10-23 07:42	Form me, it is clear, one can diagnose here sinus infiltration by CD30+/EMA+ anaplastic tumor..., if ALK1 is positive, this could be indeed an ALCL, but to substantiate the histogenetic lineage, particulerly CD2, CD3 and CD43 as well as TIA1, granzyme and perforin stains should be performed.
nurija 2007-10-23 08:06	I am not sure but for me all cells there are within the vessels not around the vessels it is reason why we had stain CD34,I agree with all of you phenotype of this cells is ALCL (ALK+,CD20+,CD30+ and EMA+)
Mueller-Hermelink 2007-10-23 15:14	If CD20 is indeed positive, the case appears likely to be one of those often IgA positive variants of ALCL , that originally have been described as carrying-full-length ALK 1 protein , but more recently were found to carry the variant translocation TPM-ALK. This would also explain the localization within the sinus system of the medullary sinuses.
semir 2007-10-23 15:52	Have just added two figures with ALK staining.
tzankov 2007-10-24 09:02	would you please show the CD20 stains!
Mueller-Hermelink 2007-10-24 17:31	The nuclear Alk1 staining is in favour of conventional ALCL with t (2;5).therefore this is most likely ALCL - Alk1 + ( of T -type).
hurwitz 2007-11-12 20:53	Thanks for this nice case. Prof. Müller Hermelinks comment should be regarded as the final diagnosis.
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