Intraoperative assessment of sentinel lymph nodes in patients with breast carcinoma: accuracy of rapid imprint cytology compared with definitive histologic workup

A Systematic Review and Meta-analysis of Touch Imprint Cytology and Frozen Section Biopsy and Their Comparison for Evaluation of Sentinel Lymph Node in Breast Cancer

INTRODUCTION

Evaluation of axillary lymph nodes after sentinel lymph node biopsy (SLNB) in breast cancer is mostly done by intra-operative frozen section biopsy (FSB) and/ or touch imprint cytology (TIC). In this systematic review and meta-analysis, we have compared the accuracy of the two modalities.

METHODS

PubMed, EMBASE, and Cochrane electronic databases were searched for articles comparing TIC with FSB. Articles were assessed for methodological and reporting quality. The main summary measures were pooled sensitivity, pooled specificity, and diagnostic accuracy using bivariate generalized linear mixed models using random effects.

RESULTS

Fourteen studies were included. The pooled sensitivity, specificity, and diagnostic accuracy for FSB were 78%, 100%, and 98.57%. For TIC, the pooled sensitivity, specificity, and diagnostic accuracy were 74%, 98%, and 98.37%. For both methods, visual inspection of summary ROC curves and of forest plots did not show significant heterogeneity.

CONCLUSION

TIC showed comparable sensitivity, specificity, and accuracy to FSB and hence can be used as its substitute as a rapid and economical test for the detection of axillary lymph node metastasis during SLNB especially in low-resource settings.

Axillary management based on American college of surgeons oncology group Z0011 criteria makes it possible to omit intraoperative diagnosis of sentinel lymph nodes in early breast cancer patients

The ACOSOG Z0011 trial has resulted in the omission of axillary lymph node dissection (ALND) in early breast cancer patients with one or two metastatic sentinel lymph nodes (SLNs). There has been increasing interest in the necessity of intraoperative assessment of SLNs in patients treated based on the Z0011 criteria. We evaluated the utility of intraoperative assessment in these eligible patients. A total of 1396 patients were treated following the Z0011 criteria from April 2012 to December 2019. We examined the proportion and clinicopathological features of patients who underwent ALND due to three or more metastatic SLNs and the sensitivity of intraoperative assessment. Only 16 (1.1%) patients had three or more metastatic SLNs diagnosed by intraoperative assessment, and they immediately underwent ALND. Of the clinicopathological factors, high clinical tumor stage (p = 0.002) and high Ki-67 labeling index value (p = 0.056) were more likely to be associated with the presence of three or more metastatic SLNs. The major independent risk factor for three or more metastatic SLNs was high clinical tumor stage (OR 3.94 [95% CI 1.42-11.0]; p = 0.009). Intraoperative assessment had low sensitivity (70.5%) and a high false-negative rate (29.5%) in detecting SLN metastases. The main finding of our study was the small proportion of patients who required ALND due to three or more metastatic SLNs according to the Z0011 criteria. The Z0011 strategy enables intraoperative assessment of SLNs to be omitted in early breast cancer patients.

A prospective feasibility study applying the ACOSOG Z0011 criteria to Japanese patients with early breast cancer undergoing breast-conserving surgery

BACKGROUND

In patients undergoing breast-conserving surgery and having positive sentinel lymph nodes (SLNs), the ACOSOG Z0011 trial showed equivalent loco-regional outcomes for patients receiving SLN dissection (SLND) alone and those receiving axillary lymph node dissection (ALND). We conducted a prospective single-arm study to confirm the applicability of the Z0011 criteria to Japanese patients with breast cancer.

METHODS

Patients meeting the Z0011 inclusion criteria and providing consent to receive no additional ALND were prospectively enrolled at the Osaka International Cancer Institute from April 2012 to December 2016. Cumulative incidence of loco-regional recurrence was estimated and compared to that of the Z0011 study.

RESULTS

Among a total of 881 patients who underwent breast-conserving surgery, 189 fulfilling the Z0011 criteria were enrolled and eligible for the subsequent analysis. Adjuvant chemotherapy was given to 113 (59.8%) patients, adjuvant hormone therapy to 170 (89.9%), and whole breast irradiation to 183 (96.8%). The frequency of tumors with positive lymphovascular invasion (p < 0.0001) and macrometastases in SLNs (p < 0.0001) were significantly higher in our study than in the Z0011 study. At the median follow-up of 36 months (range 10-64 months), only 2 of 189 patients (1.1%) experienced loco-regional recurrence. The 5-year cumulative rate of loco-regional recurrences was 1.3% (95% CI 0-3.1%), and the 3-year distant DFS rate was 96.8% (95% CI 94.0-99.6%).

CONCLUSIONS

Our prospective study showed that it is feasible to apply the Z0011 strategy to Japanese patients with clinically node-negative breast cancer undergoing breast-conserving surgery with planned whole breast irradiation.

Clinical significance of MSKCC nomogram on guiding the application of touch imprint cytology and frozen section in intraoperative assessment of breast sentinel lymph nodes

The widely practiced intra-operative methods for rapid evaluation and detection of sentinel lymph node (SLN) status include frozen section (FS) and touch imprint cytology (TIC). This study optimized the use of TIC and FS in the intra-operative detection of breast SLNs based on the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram. Three hundred forty-two SLNs were removed from 79 patients. SLN metastatic probability was assessed by the MSKCC nomogram. The SLNs underwent intra-operative TIC and FS, as well as routine post-operative paraffin sections (RPSs). The relationships between TIC, FS, and SLN metastatic probability were analyzed. Overall, TIC was more sensitive than FS (92.31% vs. 76.92%), while TIC specificity was inferior to FS specificity (84.85% vs. 100%). In addition, the best cut-off value for TIC based on the MSKCC nomogram was inferior to the best FS cut-off value (22.5% vs. 34.5%). All patients with a MSKCC value <22.5% in the present study were negative based on FS and RPS, while the true-negative and false-positive rates for TIC were 92.5% and 7.5%, respectively. Thus, early breast cancer patients, based on a MSKCC value <22.5%, can safely avoid FS, but should have TIC performed intra-operatively. Patients with a MSKCC value >22.5% should have TIC and FS to determine the size of metastases, whether or not to proceed with axillary lymph node dissection, and to avoid easily missed metastases.

Sentinel lymph nodes for breast carcinoma: an update on current practice

Sentinel lymph node (SLN) biopsy has been established as the standard of care for axillary staging in patients with invasive breast carcinoma and clinically negative lymph nodes (cN0). Historically, all patients with a positive SLN underwent axillary lymph node dissection (ALND). The ACOSOG Z0011 trial showed that women with T1-T2 disease and cN0 who undergo breast-conserving surgery and whole-breast radiotherapy can safely avoid ALND. The main goal of SLN examination should be to detect all macrometastases (>2 mm). Gross sectioning of SLNs at 2-mm intervals and microscopic examination of one haematoxylin and eosin-stained section from each SLN block is the preferred method for pathological evaluation of SLNs. The role and timing of SLN biopsy for patients who have received neoadjuvant chemotherapy is controversial, and continues to be explored in clinical trials. SLN biopsies from patients with invasive breast carcinoma who have received neoadjuvant chemotherapy pose particular challenges for pathologists.

Intraoperative Frozen Section Evaluation of Sentinel Lymph Nodes in Breast Carcinoma: Single-Institution Indian Experience

Sentinel lymph node biopsy is an established way of predicting axillary nodal metastasis in early breast cancer. Intraoperative frozen sections (FS) of sentinel lymph nodes (SLNs) can be used to detect metastatic disease, allowing immediate axillary lymph node dissection. The purpose of this study was to evaluate the accuracy of intraoperative frozen sections in evaluation of sentinel lymph nodes in cases of breast cancer. Between March 2006 and August 2010, a total of 164 patients with clinically node-negative operable breast cancer were subjected to sentinel lymph node biopsy of axillary lymph nodes using preoperative peritumoral injection of radioactive colloid and methylene blue. Intraoperative identification of sentinel nodes was done using a handheld gamma probe and identification of blue-stained nodes. The nodes were sent for frozen section examination. The results of frozen section were compared with the final histopathology. Out of the 164 cases, metastases were detected in SLN by frozen section in 38 cases. There were three false-negative cases (all showing micrometastasis on final histopathology). FS had sensitivity of 92.6 %, specificity of 100 %, and overall accuracy of 98.1 %. The positive predictive value was 100 %, and the negative predictive value was 97.6 %. FS for diagnosis of metastasis of SLNs is reliable. Patients with negative SLNs by the FS diagnosis can avoid reoperation for axillary lymph node dissection. However, FS may fail to detect micrometastases, especially in cases with small tumors.

Ambulatory sentinel lymph node biopsy preceding neoadjuvant therapy in patients with operable breast cancer: a preliminary study

Background

Sentinel lymph node biopsy (SNB)-oriented stepwise treatment under local anesthesia has been performed in the outpatient-ambulatory setting in patients receiving neoadjuvant therapy (NAT). We retrospectively reviewed our preliminary experience of ambulatory SNB in breast cancer patients scheduled to undergo NAT to evaluate the usefulness and feasibility of this method as a minimally invasive, stepwise treatment protocol.

Methods

We retrospectively identified 56 patients with breast cancer without obvious nodal involvement who were scheduled to receive NAT before breast surgery. SNB was performed under local anesthesia in an ambulatory outpatient setting before the initiation of NAT.

Results

The average number of removed sentinel lymph nodes was 1.9. Identification of the sentinel node was possible in all cases, and macrometastasis was observed in six cases (10.7%). Micrometastasis was observed in five cases, while isolated tumor cells were noted in six cases. There were no delays in the initiation of NAT as a result of complications of SNB.

Conclusions

This pilot study demonstrated the safety and feasibility of ambulatory SNB prior to NAT. Further studies are warranted to assess the strict indications, patient satisfaction, and medical economics of this procedure.

Role of imprint/exfoliative cytology in ulcerated skin neoplasms

Imprint cytology is a method of studying cells by taking an imprint from the cut surface of a wedge biopsy specimen or from the resected margins of a surgical specimen. It is rapid, simple and fairly accurate. Exfoliative cytology is an offshoot from the imprint cytology where in cells obtained from the surface of ulcers, either by scrape or brush, are analyzed for the presence of malignant cells. We undertook this study to see the role of imprint/exfoliative cytology in the diagnosis of ulcerated skin neoplasm and to check the adequacy of resected margins intra-operatively. This was a prospective investigative study conducted from September 2003 to July 2005. All patients presenting to surgical clinic with ulcerated skin and soft tissue tumours were included in the study. A wedge biopsy obtained from the ulcer and imprint smears were taken from the cut surface. Exfoliative cytology was analyzed from the surface smears. Wedge biopsy specimen was sent for histopathological (HPE) examination. The cytology and HPE were analyzed by a separate pathologist. Imprint cytology was also used to check the adequacy of resected margins in case of wide excision. This was compared with final HPE. Total of 107 patients was included in the present study and 474 imprint smears were done, with an average of 4.43 slides per lesion. Out of 59 wide excision samples, 132 imprint smears were prepared for assessing resected margins accounting for an average of 2.24 slides per each excised lesion. On combining imprint cytology with exfoliative cytology the overall sensitivity, specificity and positive predictive value were 90.38 %, 100 % and 90.38 % respectively. Only one out of 59 cases had a positive resected margin which was not picked by imprint cytology. Imprint cytology can be used for rapid and accurate diagnosis of various skin malignancies. It can also be used to check the adequacy of the resected margin intraoperatively.

Adjunctive imprint cytology of core needle biopsy specimens improved diagnostic accuracy for breast cancer

Objective

Recently, therapies targeting the biological characteristics of individual cancers according to markers indicating underlying molecular biological mechanisms have become available. Core needle biopsy (CNB) is widely used, not only to diagnose, but also to determine therapeutic strategies, in patients with breast cancer. Although the diagnostic accuracy of CNB is acceptably high, false-negative results have occasionally been encountered.

Methods

The results of adjunctive imprint cytology (AIC) coinciding with CNB in 2,820 patients suspected to have breast cancer were retrospectively reviewed. The feasibility and clinical usefulness of AIC-assisted diagnosis were analyzed.

Results

Fourteen-hundred and sixty-four cases were diagnosed as not malignant using CNB alone. Forty-seven of 1464 cases were suspected to be malignant on a cytological review of AIC, and 42 were confirmed to be breast cancer on additional biopsies. The combination of CNB and AIC achieved a sensitivity of 100% (1398/1398) and a specificity of 99.6% (1417/1422). Small lesions and large noninvasive- or scirrhous-type carcinomas were the common features of the CNB-negative/AIC-positive cases.

Conclusions

Adjunctive imprint cytodiagnosis is a simple and easy procedure that assists the pathological diagnosis of breast cancer using CNB and therefore serves as a possible novel standard application.

Novel diagnostic procedure for determining metastasis to sentinel lymph nodes in breast cancer using a semi-dry dot-blot method

We developed an easy, quick and cost-effective detection method for lymph node metastasis called the semi-dry dot-blot (SDB) method, which visualizes the presence of cancer cells with washing of sectioned lymph nodes by anti-pancytokeratin antibody, modifying dot-blot technology. We evaluated the validity and efficacy of the SDB method for the diagnosis of lymph node metastasis in a clinical setting (Trial 1). To evaluate the validity of the SDB method in clinical specimens, 180 dissected lymph nodes from 29 cases, including breast, gastric and colorectal cancer, were examined. Each lymph node was sliced at the maximum diameter and the sensitivity, specificity and accuracy of the SDB method were determined and compared with the final pathology report. Metastasis was detected in 32 lymph nodes (17.8%), and the sensitivity, specificity and accuracy of the SDB method were 100, 98.0 and 98.3%, respectively (Trial 2). To evaluate the efficacy of the SDB method in sentinel lymph node (SLN) biopsy, 174 SLNs from 100 cases of clinically node-negative breast cancer were analyzed. Each SLN was longitudinally sliced at 2-mm intervals and the sensitivity, specificity, accuracy and time required for the SDB method were determined and compared with the intraoperative pathology report. Metastasis was detected in 15 SLNs (8.6%), and the sensitivity, specificity, accuracy and mean required time of the SDB method were 93.3, 96.9, 96.6 and 43.3 min, respectively. The SDB method is a novel and reliable modality for the intraoperative diagnosis of SLN metastasis.

Factors associated with the misdiagnosis of sentinel lymph nodes using touch imprint cytology for early stage breast cancer

Accurate intraoperative diagnosis of sentinel node metastasis enables the surgeon to make an immediate decision to proceed to axillary lymph node dissection (ALND), thereby avoiding the economic and psychological costs of a second operation. The present study aimed to evaluate the clinical value of touch imprint cytology (TIC) and investigate the potential factors associated with misdiagnosis. A total of 366 patients with Tis-T2 breast carcinoma were included after undergoing successful sentinel lymph node biopsy (SLNB). TIC was routinely performed intraoperatively, and the results were compared with definitive histological assessments of serial sections (SS) with hematoxylin and eosin (H&E) staining. A total of 992 SLNs from 366 patients were used in the study. Based on the final histological diagnosis, the sensitivity, specificity and overall accuracy of TIC was 76.6, 98.8 and 92.3%, respectively, on a per patient basis, and 79.9, 98.9 and 96.1%, respectively, on a per node basis. TIC was significantly more sensitive for macrometastasis than micrometastasis (80.0 vs. 28.6%, P<0.01). Of 9 total 'false positives', 3 were due to micrometastasis which were not identified by serial section with H&E staining, 4 were actual false-positives which were due to interpretation error, and 2 were due to sampling error. The majority of the false-negatives (28 of 30 SLNs) were due to micrometastasis in the SLNs (sampling error). In conclusion, TIC is feasible for clinical use and is able to detect macrometastasis in the SLNs of early stage invasive breast cancer patients with an acceptable accuracy while its ability to detect micrometastasis is limited.

[Sentinel node in breast cancer. Experience of the Salah-Azaïz Institute of Tunis]

INTRODUCTION

Breast cancer screening increased the ratio of small tumours. These tumours have a low lymph node metastatic potential. Sentinel node detection allows detecting axillary lymph node invasion without the morbidity of complete axillary lymph node dissection.

OBJECTIVES

In this study we report the results of the learning curve of sentinel node detection in the Institut Salah-Azaïz of Tunis.

MATERIALS AND METHODS

It is a prospective study between January 2004 and December 2005 in which 115 patients were included with breast cancer less than 3 cm without antecedents of breast surgery. All these women had sentinel node dissection by a colorimetric method and 30% had a combined method (colorimetric and isotopic).

RESULTS

The rate of detection was 97.3% (n = 112). An extemporaneous examination was performed in 91 patients. The rate of negative forgery of the extemporaneous examination was 4.3% and the sensitivity of 95.7%. There are no false positive with the extemporaneous exam. The sentinel lymph node was the only node invaded in 15 patients (44%). In 3 patients, the sentinel node was healthy whereas the axillary dissection was positive, so the false negative rate is about 2.6%.

CONCLUSION

Sentinel node dissection is a reliable and feasible technique. It however requires a training of the surgeon, the pathologist and the nuclear doctor. It allows to reduce the morbidity of the treatment of the breast cancer by avoiding "useless" axillary dissection out in patients without node invasion. The increase in the number of the small cancers discovered during screening makes it possible to increase the number of patients who can profit from this technique.

Intraoperative cytologic evaluation of sentinel lymph nodes in patients with breast carcinoma by scrape preparation

Intraoperative evaluation of sentinel lymph nodes (SLNs) in patients with breast carcinoma allows surgeons to complete axillary lymph node dissection in one procedure if any SLN shows metastasis. The accuracy of intraoperative pathological diagnosis is critical for decision-making. The purpose of this study was to evaluate our rapid intraoperative cytologic diagnosis of SLN through comparing with the final surgical pathologic diagnosis of the corresponding lymph nodes. A total of 454 SLNs from 159 consecutive female patients with a preoperative diagnosis of breast carcinoma over 3-year period were included in this study. After gross examination of each bisected lymph node, a scrape preparation was prepared for each submitted lymph node and was stained by the rapid Papanicolaou method. The intraoperative cytologic diagnosis was compared with the final surgical pathologic diagnoses. The overall sensitivity of intraoperative cytology was 52.5% with specificity of 100%. There were 17 false-negative cases. Of them, six nodes had isolated tumor cells, seven nodes had micrometastasis (0.2-2 mm), and four nodes had macrometastasis (>2 mm). There were no interpretive errors identified. The size of metastasis and tumor grade appeared to be significant factors in detecting metastasis by cytology. In addition, subsequent non-SLN involvement was 9% in patients with micrometastasis versus 50% in patients with macrometastasis (P < 0.05). Our study shows that the intraoperative cytologic evaluation of SLNs in breast carcinoma is a reasonably accurate method. The majority of false-negative cases were due to micrometastasis and isolated tumor cells.

Técnica del ganglio centinela en la cirugía del cáncer de mama en un hospital sin servicio de medicina nuclear

INTRODUCTION

Knowledge of lymph node stage is the most important prognostic factor in breast cancer. The sentinel lymph node biopsy technique (SLNBT), initially developed to avoid unnecessary dissection in melanoma, has been shown to be able to predict the axillary stage of breast cancer. The difficulty of applying the SLNBT in hospitals without a nuclear medicine service has led to the existence of external teams that allow these hospitals to apply the technique.

OBJECTIVE

To test the application of the SLNBT in our hospital which has no nuclear medicine service.

PATIENTS AND METHODS

Coinciding with the validation of the SLNBT in the Germans Trias i Pujol Hospital in Badalona in November 1999, and with their help, the Centre Hospitalari de Manresa began to apply this technique. In 2002, the technique was used in all the hospitals of the ALTHAIA-Xarxa Assistencial de Manresa. From November 1999 to June 2005, the technique was applied in 163 patients.

RESULTS

Of the 163 patients, the technical success rate was 97.55%. In 98% of the patients, the sentinel lymph node was found in the axilla. In 10.7% of the patients, the node was found in the internal mammary basin. Twenty-six percent of the axillas had metastases of over 2 mm, and 16% had micrometastases. One hundred and five patients were spared axillary dissection.

CONCLUSIONS

The SLNBT can be performed in a hospital without a nuclear medicine service. This technique improves and simplifies the surgical technique and reduces length of hospital stay and morbidity.

Intraoperative examination of sentinel lymph nodes by immunohistochemical staining in patients with breast cancer

AIM

To performed a prospective investigation of the relative merits of rapid cytokeratin immunohistochemical (CK-IHC) staining of the SLN removed during the operation of breast cancer patients.

STUDY DESIGN

Between December 2002 and March 2004, 62 patients with T1 and T2 breast cancer were enrolled after undergoing successful sentinel lymph node biopsy. Eighty-nine sentinel lymph nodes (mean number, 1.44) were biopsied and first examined by hematoxylin-eosin (H&E) stained frozen section. All the tumour free sentinel lymph nodes by H&E stained frozen section were immunostained for cytokeratin using a rapid immunohistochemical assay (Cytokeratin (PAN), 1:50, Novocastra Lab., Newcastle, UK) during the operations.

RESULTS

Rapid IHC staining revealed seven positive sentinel lymph nodes that were negative for metastasis by H&E staining. This study showed a sensitivity of 92.86%, a specificity of 100%, an accuracy of 98.9%, and a negative predictive value of 98.7%.

CONCLUSIONS

The intraoperative examination of sentinel lymph nodes is an accurate and effective way of predicting the axillary lymph node status of patients with breast cancers.

Intraoperative sentinel lymph node examination by frozen section, immunohistochemistry and imprint cytology during breast surgery – A prospective study

The aim of this study was to compare the sensitivity of intraoperative frozen section with hematoxyllin-eosin (H&E) staining, immunohistochemistry (IHC) or imprint cytology (IC) in the analysis of sentinel node (SN) in breast cancer. Towards this end, a prospective study of 102 patients undergoing mastectomy or sector resection with SN biopsy was conducted. Frozen sections of SN with H&E, IHC staining and IC had sensitivities of 73.5%, 75.5% and 51.0%, respectively. The combination of H&E and IHC raised the overall sensitivity to 83.7%. Macrometastases (>2 mm) were detected in 100% of the cases with H&E, 92.6% with IHC and 81.5% with IC; and micrometastases (2 mm) in 35.0%, 45.0% and 5.0%, respectively. The combination of H&E and IHC staining raised the sensitivity to 55.0%. Frozen-section analysis with H&E staining showed high sensitivity in detecting macrometastases but not micrometastases. The sensitivity for detection of micrometastases was not substantially increased by the use of intraoperative IHC. Imprint cytology did not provide any additional information.

Rapid Intraoperative Immunohistochemical Evaluation of Sentinel Lymph Nodes for Metastatic Breast Carcinoma

OBJECTIVE

Sentinel lymph node (SLN) biopsy is an integral part of the surgical management of patients with breast cancer. Rapid immunohistochemistry (RIHC) has the potential to increase detection of metastatic carcinoma at the time of frozen section consultation. The authors assessed the accuracy and turnaround time of a newly developed RIHC method for pancytokeratin (RIHC-CK).

METHODS

Sixty-six SLNs from 32 patients with breast carcinoma were examined for metastasis using the Zymed Sentinel Lymph Node Rapid IHC Kit. Intraoperative frozen sections (6 mum) of the SLNs were incubated with Zymed anti-pan-cytokeratin/HRP conjugate, diaminobenzidine (DAB), and stained with hematoxylin. Slides were ready within 8 minutes and were interpreted as positive or negative for metastatic carcinoma. Results were compared with previous intraoperative touch preparations, frozen sections, hematoxylin and eosin (Perm H&E), and AEl/3-immunostained permanent sections (Perm CK).

RESULTS

Fourteen lymph nodes (19%) in 13 patients tested positive for metastatic carcinoma in Perm H&E, the gold standard. RIHC-CK had the highest sensitivity (92%) of the intraoperative tests, compared with touch preparations (64%) and frozen sections (80%). RIHC-CK showed 94% accuracy, compared with 96% (frozen section) and 93% (touch preparation). The RIHC technique took 8 minutes and was easy to perform and interpret.

CONCLUSIONS

Zymed RIHC is a sensitive method for detecting breast cancer metastases in SLNs. The speed, accuracy, and ease of interpretation of the test allow for recognition of micrometastases (<2 mm) that might otherwise be undetectable by current methods of intraoperative evaluation. The prognostic significance and effect on surgical management of micrometastases in SLNs have yet to be determined.

Evaluation of sentinel node identification with isosulfan blue in gastric cancer

AIMS

The aim of this study was to clarify whether the metastasis of gastric cancer can be detected by identifying the sentinel lymph nodes (SNs) using only lymphatic dye.

METHOD

The study was based on 101 patients clinically diagnosed with T1 and T2 gastric cancer. Isosulfan blue was intraoperatively injected within the submucosal layer around the lesion through an endoscope and blue stained nodes (BNs) were identified as SNs and harvested. Standard radical gastrectomy with D2 lymphadenectomy was performed on all patients and SNs and other nodes were evaluated.

RESULTS

Out of 101 patients, 21 had lymph-node metastases. The accuracy of SN identification was 97.0% (98/101) and the metastasis detection rate was 85.7% (18/21). With improvement of the manoeuvre in the latter 84 cases, the detection rate was elevated up to 100.0% (18/18), as was the accuracy (84/84).

CONCLUSION

The sentinel concept using lymphatic dye is applicable to gastric cancer, but the identification of SNs with lymphatic dye requires some practice. Furthermore, the issue of intraoperative metastasis detection remains to be resolved.

Intraoperative Imprint Cytology in Assessment of Sentinel Lymph Nodes and Lumpectomy Surgical Margins

Intraoperative imprint cytology (IIC) in the assessment of sentinel lymph nodes (SNs) allows immediate, cost-effective axillary lymph node dissection. IIC diagnosis is accurate in up to 100% of grossly abnormal SNs. Despite overall low sensitivity for grossly negative SNs, the benefits of immediate complete axillary lymph node dissection offset the increased risk of missing micrometastases or loss of isolated tumor cells (ITCs) by performing frozen section. IIC of the lumpectomy margins is rapid, accurate, and cost effective. It allows re-excision during initial surgery if needed with better cosmetic result. It is a useful adjunct to, and frequently a replacement for frozen section in many centers. Cytopathologists must familiarize themselves with both advantages and pitfalls of IIC to avoid errors.

Meta-analysis of sentinel node imprint cytology in breast cancer

BACKGROUND

Intraoperative diagnosis of breast cancer metastases in axillary sentinel nodes is desirable to avoid a second operation for lymphadenectomy. Imprint or touch-preparation cytology is a popular technique that has high specificity and a wide range of sensitivity.

METHODS

A systematic search of electronic databases was performed. Included articles were assessed for methodological and reporting quality. Random-effects model pooled estimates of sensitivity and specificity were calculated. Single-variable and multivariable meta-regression analyses were performed for predictors of sensitivity.

RESULTS

Thirty-one studies were included; all were of good methodological quality but reporting quality varied. Pooled sensitivity of imprint cytology was 63 (95 per cent confidence interval (c.i.) 57 to 69) per cent and specificity was 99 (95 per cent c.i. 98 to 99) per cent. Pooled sensitivity for macrometastases was 81 per cent and that for micrometastases 22 per cent. Mean or median primary tumour size (P = 0.004), the prevalence of metastases (P = 0.103) and the proportion of micrometastases (P = 0.022) were significant risk factors in single-variable meta-regression analysis. Only the proportion of micrometastases remained significant in multivariable analysis. Frozen sectioning had better sensitivity than imprint cytology in three of four direct comparisons.

CONCLUSION

Imprint cytology is simple and rapid, and has good sensitivity for macrometastases. The significance of poor sensitivity for micrometastases will be determined by trials investigating their natural history.

Intraoperative detection of lymph node micrometastasis with flow cytometry in non–small cell lung cancer

OBJECTIVE

We sought to determine whether cytokeratin-positive cells can be detected as markers of lymph node metastasis by using flow cytometry within a time frame suitable for intraoperative decision making in non-small cell lung cancer.

METHODS

Five lymph nodes from each of 20 patients with non-small cell lung cancer were randomly selected for study. Each node was divided longitudinally into 3 pieces: one piece for flow cytometry, one for immunohistochemical staining, and the last for conventional hematoxylin and eosin staining. In both flow cytometry and immunohistochemistry, cytokeratin-positive cells were detected with the fluorescein isothiocyanate-conjugated anti-cytokeratin antibody AE1/AE3.

RESULTS

Cytokeratin-positive nodes were detected by means of flow cytometry within 40 minutes. Eight (8%) of the 100 lymph nodes from 4 (20%) of the 20 patients were deemed positive for metastasis on the basis of conventional histologic examination. By contrast, 33 (33%) lymph nodes from 13 (65%) patients were deemed positive on the basis of immunohistochemical cytokeratin staining, and 38 (38%) lymph nodes from 14 (70%) patients were deemed positive on the basis of flow cytometric cytokeratin-positive cell detection. All nodes deemed positive for metastasis on the basis of conventional and immunohistochemical methods were also positive on flow cytometry.

CONCLUSIONS

Flow cytometry enables rapid intraoperative diagnosis of nodal metastasis in patients with non-small cell lung cancer. Flow cytometric detection of cytokeratin-positive cells within lymph nodes correlates with their immunohistochemical detection, and its level of sensitivity is greater than that of conventional histologic staining and about equal to that of immunohistochemical staining.

A Practical Approach to Intraoperative Evaluation of Sentinel Lymph Node Biopsy in Breast Carcinoma and Review of the Current Methods

BACKGROUND

Sentinel lymph node (SLN) biopsy is increasingly becoming an alternative method for assessing axillary status in breast carcinoma patients. Intraoperative SLN evaluation can potentially select patients for immediate axillary clearance and spare most of them a second surgical procedure. Nevertheless, no standard protocol for intraoperative SLN evaluation has been developed. The aims of this study were to establish the reliability of SLN intraoperative evaluation in breast carcinoma staging, to review the published methods currently used, and to propose a standard protocol.

METHODS

One hundred fifty-two SLNs were collected from 86 patients. Lymphoscintigraphy, blue dye, and gamma camera intraoperative controls were used for localization. Each SLN was sliced 2 mm thick and was intraoperatively evaluated by using the combination of frozen section and imprint cytology. The final examination included standard hematoxylin and eosin staining, and, in case of persistent negativity, further sectioning, including hematoxylin and eosin combined with immunohistochemistry (CAM5.2 cytokeratin), was performed.

RESULTS

The combination of frozen section and imprint cytology for intraoperative SLN evaluation yielded an intraoperative sensitivity of 78% and a specificity of 100%. All macrometastases (>2 mm) were detected during surgery, as were 2 micrometastases. Final examination detected seven more micrometastases, six of which consisted of isolated tumor cells.

CONCLUSIONS

We propose a fast, cost-effective, and accurate procedure for SLN evaluation that is useful for making intraoperative decisions, feasible for most institutions, and reliable because of its high sensitivity (100% for macrometastases) and specificity.

The results of frozen section, touch preparation, and cytological smear are comparable for intraoperative examination of sentinel lymph nodes: a study in 133 breast cancer patients

BACKGROUND

The goal of intraoperative sentinel lymph node (SLN) examination is to avoid reoperation for a positive SLN, but the ideal method of intraoperative SLN examination remains unclear, and published results vary widely.

METHODS

We evaluated the sensitivity of intraoperative frozen section (FS), touch preparation (TP), and cytological smear (CS) in 305 SLNs from 133 breast cancer patients. Each SLN was received fresh and cut into 2- to 3-mm slices; TP and CS from each cut surface and an FS of the entire SLN were obtained. Postoperative evaluation of the SLN consisted of 1 hematoxylin and eosin-stained section and of one hematoxylin and eosin-stained and one immunohistochemically stained section for cytokeratin from each of two levels 50 microm apart. Tumor cells found by any method, including immunohistochemistry, identified a positive SLN. Three pathologists blinded to the final SLN diagnosis reviewed all TP, CS, and FS; the consensus diagnosis (concordance of two or more) was used for the study.

RESULTS

FS, TP, and CS had comparable sensitivities (59%, 57%, and 59%, respectively). Each method was more sensitive in detecting macrometastases (>2 mm; 96%, 93%, and 93%, respectively) than micrometastases (< or =2 mm; 27%, 27%, and 30%, respectively). The combination of methods only marginally improved the intraoperative sensitivity. TP and CS were each responsible for a single false-positive result.

CONCLUSIONS

FS, TP, and CS are comparable for the intraoperative detection of SLN metastases, and each method is substantially better at detecting micrometastases than micrometastases. The combination of two or more techniques only marginally improves the sensitivity over that achieved by a single method.

Intraoperative cytologic diagnosis of breast sentinel lymph nodes in the routine, nonacademic setting: a highly specific test with limited sensitivity

Intraoperative determination of metastatic breast carcinoma in sentinel lymph nodes (SLNs) by cytologic methods has been proposed as highly specific and sensitive. Much of these data are derived from academic institutes with highly trained personnel and without axillary dissection occurring as a direct result of the intraoperative interpretation. This prospective study was undertaken to assess the sensitivity and specificity of cytology in the routine, private-practice, intraoperative setting. A total of 207 SLNs from 96 breast carcinoma patients were evaluated by intraoperative cytologic preparations by general surgical pathologists; positive results led to axillary lymphadenectomy. Ten nodes were positive by intraoperative cytology (IC). Permanent section analysis confirmed the presence of carcinoma in the IC-positive cases and documented carcinoma in 19 of the IC-negative cases. IC sensitivity and specificity were 34% and 100%, respectively. False-negative IC interpretations occurred in nodes with occult micrometastases (12 of 19 nodes) and lobular carcinoma (6 of 19 nodes). Only one of eight grossly positive sentinel nodes resulted in a false-negative IC. While near-perfect specificity and high sensitivity can be achieved with grossly positive sentinel nodes by IC, sensitivity is quite low in cases with micrometastatic and lobular carcinoma.

Accuracy of intraoperative imprint cytology for sentinel lymph node evaluation in the treatment of breast carcinoma

BACKGROUND

The current report provides results from a large retrospective analysis of intraoperative imprint cytology performed on axillary sentinel lymph nodes (IIC(N)) removed over the course of 2137 breast surgeries (4905 lymph nodes). It is hoped that these results may serve as benchmarks for those interested in using this technique.

METHODS

The current study included 2078 patients with T1-2 invasive breast carcinoma who underwent sentinel lymph node biopsy (SLNB) and IIC(N). Lymph nodes were bivalved, imprinted, stained with Diff-Quik (Baxter Diagnostics, McGaw Park, IL), and reviewed by a cytopathologist. A positive intraoperative diagnosis led to immediate complete axillary lymph node dissection (CALND). On final pathology, lymph nodes found to be negative on hematoxylin and eosin staining were submitted for cytokeratin staining.

RESULTS

Of the 2137 cases for which SLNB was performed, 673 were found to have positive lymph node status on final pathology. Of these 673 cases, 359 were identified by IIC(N), resulting in a sensitivity rate of 53.3%. The specificity and overall accuracy rates for this technique were 99.5% and 85.0%, respectively. In IDC cases, IIC(N) had a sensitivity rate of 55.5%, compared with 38.7% in ILC cases. Based on these results, the reoperative CALND rate was calculated to be approximately 14.7%, with 54.5% of these reoperative procedures being performed for cases in which lymph nodes positive only for micrometastases were found. Macrometastasis-positive lymph nodes that went undetected by IIC(N) were present in only 154 of the 2137 cases examined (7.2%).

CONCLUSIONS

IIC(N) accurately predicts final lymph node status in 85.0% of patients. Although the accuracy of this technique varies with tumor size and type, IIC(N) remains a time-efficient and cost-effective adjunct to SLNB.

Comment éviter les aléas de l’examen extemporané du ganglion sentinelle dans le cancer du sein ?

The sentinel lymph node procedure is now admitted by many teams for axillary evaluation in the early stage of breast cancer. The classical technique consists in an intraoperative examination of the sentinel lymph node under general anaesthesia during tumorectomy, deciding whether or not complete axillary lymphadenectomy must be done. Intraoperative examination seems to us to have a poor predictive value. In the case of a false positive, the surgeon would perform lymphadenectomy unnecessarily, while a false negative would mean that the patient would have to be re-operated for lymphadenectomy once the definitive results have become available. For all these reasons, we propose the detection of the sentinel lymph node under local anaesthesia and to await its definitive analysis before carrying out tumorectomy on the patient and axillary lymphadenectomy if necessary under general anesthesia. Hence, we consider that the best way to avoid the uncertainties of an intraoperative examination of the sentinel lymph node is not to carry out intraoperative examinations.

Intraoperative Examination of Sentinel Nodes in Breast Cancer: Is the Glass Half Full or Half Empty?

BACKGROUND

Intraoperative identification of positive sentinel lymph nodes in patients with breast cancer may avoid a return to the operating room.

METHODS

In a group of 402 consecutive patients with primary breast cancer who underwent sentinel lymph node biopsy, an intraoperative examination (IE) was obtained in 236 cases either by frozen section (FS; n = 68) or by touch preparation cytology (TP; n = 168).

RESULTS

IE had an accuracy of 89% (209 of 236), but it identified only 52 of 77 positive cases (sensitivity, 68%). There were 25 false-negative cases (13.7%), of which 7 were macrometastases and 18 by micrometastases (P < .001). Six macrometastases were missed by TP and one by FS (P = .9). There were two false-positive cases (3.7%). Overall, 48 (20%) of 236 patients avoided a delayed return to the operating room for a completion lymphadenectomy because of IE findings. This occurred in 10% of patients with tumors <1 cm in diameter, in 20% of those with tumors between 1 and 2 cm, and in 34% of those with tumors >2 cm in diameter (P = .05). The cost savings for the Italian Health System amounted to 198,040 (US$223,794) in these patients.

CONCLUSIONS

IE has acceptable sensitivity for lymph node macrometastases, but it is a weak tool for diagnosing micrometastases. FS and TP are roughly equivalent. IE allows management changes, because approximately 20% of all patients are expected to undergo synchronous axillary dissection, and it is particularly helpful in T2 patients. This may allow substantial cost savings for the health-care system.

Cytokeratin staining for intraoperative evaluation of sentinel lymph nodes in patients with invasive lobular carcinoma

BACKGROUND

Frozen section and intraoperative imprint cytology (IIC(N)) are 2 methods used for intraoperative pathologic assessment of sentinel lymph nodes (SLNs). The SLN evaluation of patients with invasive lobular carcinoma (ILC) results in a relatively high number of false-negative results using either of these methods. The purpose of this study was to evaluate the added benefits that intraoperative immunohistochemical-cytokeratin staining (I(CK-IHC)) can bring to IIC(N) in the evaluation of SLN in patients with ILC.

METHODS

A total of 59 breast cancer patients with ILC underwent an SLN biopsy evaluated by our standard IIC(N) assessment in addition to I(CK-IHC). The results of IIC(N) with I(CK-IHC) were compared with the final histopathologic assessment consisting of standard hematoxylin and eosin staining and additional cytokeratin staining of nodes.

RESULTS

Intraoperative evaluation of SLN using IIC(N) and I(CK-IHC) correctly diagnosed the nodal status in 45 of 59 (76.3%) patients. On final histopathologic assessment, 31 of 59 (52.5%) patients were found to have positive nodes. Using I(CK-IHC), 17 of these 31 positive cases (54.8%) were detected. Using IIC(N) alone, without the benefit of I(CK-IHC), only 13 of 31 (41.9%) positive cases were detected intraoperatively.

CONCLUSIONS

For patients with ILC, I(CK-IHC) staining in addition to IIC(N) improves accuracy over using IIC(N) alone. In this study, I(CK-IHC) staining demonstrated a 12.9% improvement in the detection of SLN metastases in patients with ILC. Cytopathologists should consider employing I(CK-IHC) staining to evaluate the touch-imprint slides of SLN in ILC patients.

Imprint Cytology for Detecting Metastasis of Lung Cancer in Mediastinal Lymph Nodes

BACKGROUND

Lymph node metastasis of lung cancer has been evaluated with histologic examination. We studied the usefulness of cytologic diagnosis for detecting metastasis of lung cancer in mediastinal nodes.

METHODS

Five hundred twelve stations of mediastinal nodes in 157 patients with lung cancer were excised for staging of the disease through mediastinoscopy or thoracoscopy. Among them, 474 stations of mediastinal nodes in 151 patients were examined for metastasis both with imprint cytology and with hematoxylin-eosin histology independently. The final diagnostic decision was made by overall pathologic information, including cytology and histology. The diagnostic accuracies were compared between cytologic and histologic examinations.

RESULTS

Cytologic examination identified 66 positive stations and 2 suspicious stations in 45 patients, whereas histologic examination identified 61 positive stations in 42 patients. The final pathologic diagnosis was 70 positive stations and 1 suspicious station in 45 patients. The sensitivity, accuracy, and negative predictive value of cytologic examination for node metastasis were 95.7%, 99.4%, and 99.3%, respectively, and those of histologic examination were 87.1%, 98.1%, and 97.7%, respectively. On a patient basis the sensitivity, accuracy, and negative predictive value of cytologic examination were 100%, 100%, and 100%, respectively, whereas those of histologic examination were 93.8%, 98.0%, and 97.2%, respectively. An additional 3 patients (2.0%) who had contralateral mediastinal node metastasis diagnosed only with cytology were identified with upstaged disease.

CONCLUSIONS

Imprint cytology for detecting metastasis of lung cancer in mediastinal nodes has high sensitivity and accuracy and is no less useful than histologic examination.

Intraoperative real-time genetic diagnosis for sentinel node navigation surgery

Sentinel node navigation surgery (SNNS) has received considerable attention for its role in deciding whether to perform neck dissection in patients with early oral cancer. However, diagnostic accuracy and its intraoperative availability of results remain important concerns. First, we shortened the examination time required for genetic diagnosis. Second, we assessed the quality of the extracted mRNA. Third, 10 patients with early N0 oral cancer underwent SNNS, using our new technique for genetic diagnosis to determine whether neck dissection was required. The examination time of our one-step reverse-transcriptase polymerase chain reaction method using a minicolumn and LightCycler was successfully shortened to 2 h, permitting intraoperative genetic diagnosis. The extracted mRNA was of high quality. Six sentinel nodes in four patients were diagnosed to be metastatic on genetic diagnosis; these patients underwent neck dissection. The other six patients avoided unnecessary surgery. We conclude that intraoperative genetic diagnosis of micrometastasis holds promise of being a sensitive method that can be used to support SNNS.

Selective intraoperative consultation for the evaluation of sentinel lymph nodes in breast cancer

BACKGROUND

Routine intraoperative evaluation of sentinel lymph nodes (SLNs) in breast cancer suffers from lack of sensitivity and consumes both time and resources. Failure to perform immediate consultation requires node-positive patients to return for delayed dissection.

METHODS

We sought to determine whether selective use of intraoperative pathology consultation (IOC), based on the surgeon's clinical suspicion for metastases, would be accurate, avoid unnecessary consultations, and have a similar rate of delayed axillary dissection. We performed a retrospective chart review of two cohorts of clinically node-negative patients with invasive breast cancer undergoing axillary lymph node dissection (ALND). Selective pathology evaluation was performed in the study group and mandatory evaluation in the control group.

RESULTS

The axillary basins of 327 patients undergoing routine IOC were compared with those of 91 patients in whom selective IOCs were requested. Twenty-eight consultations (31%) were obtained in the selective group. Selective consultation changed intraoperative management in 11 of 28 patients (39%) compared to 46 of 327 (14%) in the routine group (P = 0.005). The mean SLN metastasis size was 9.6 mm compared to 1.5 mm in patients in whom consultation was deferred (P = 0.003). The need for delayed ALND (17% vs. 14%) was similar in both groups, and was determined by occult metastases that were not detected by either method.

CONCLUSIONS

Selective use of IOC detects the majority of SLN macrometastases, avoids consultation that does not alter intraoperative management, and is not associated with an increased need for delayed ALND.

Comparison of Frozen Section and Touch Imprint Cytology for Evaluation of Sentinel Lymph Node Metastasis in Breast Cancer

BACKGROUND

Sentinel lymph node metastasis of breast cancer is evaluated by frozen section (FS) or touch imprint cytology (TIC). However, which of the two methods is superior remains controversial. Here we directly compared the sensitivity of these methods prospectively.

METHODS

The study included 208 SNs harvested from 107 consecutive patients with breast cancer who underwent sentinel lymph node biopsy. SNs were serially sectioned at 2-mm intervals, and two sections were subjected to intraoperative evaluation of FS with hematoxylin and eosin staining. TIC specimens were prepared from all cut surfaces and analyzed by Papanicolaou (TIC) and cytokeratin (TIC with immunohistochemistry; TIHC) immunohistochemistry.

RESULTS

Thirty-five SNs from 27 patients were positive by final histopathology. The sensitivity per sentinel lymph node of FS was 89%; it was 86% for TIC and 89% for TIHC. Among 173 negative SNs, the results of FS were concordant with final histopathology, but TIC and TIHC were positive in 1 and 5 histopathology-negative SNs, respectively. The sensitivity per patient of FS was 85%; it was 85% for TIC and 89% for TIHC. Among 80 patients with node-negative disease, the results of FS and TIC were concordant with final histopathology, whereas TIHC was positive in 3 patients (3.8% were upstaged). A slight improvement of sensitivity per patient was achieved by the combination of FS and TIC (to 89%) or FS and TIHC (to 93%).

CONCLUSIONS

The sensitivity of FS was almost equivalent to that of TIC. TIHC had a better sensitivity than FS and TIC, but it upstaged a few node-negative patients.

Accuracy of touch imprint cytology in diagnosing lung cancer

A 3-year study assessed the diagnostic accuracy of touch imprint smears in the diagnosis of lung cancer. Touch imprint smears were prepared from 90 computerized tomographic-guided core needle lung biopsies. Cytological diagnosis of touch imprint smears were correlated with the histological diagnosis of the corresponding core needle biopsy specimen, which was taken as the gold standard. The sensitivity, specificity, positive predictive value and negative predictive value of imprint smear results were 89%, 100%, 100% and 68%, respectively. There were no false positives, and all patients with small cell lung cancer were correctly diagnosed with this technique. Imprint cytology can be used to provide a rapid, preliminary diagnosis of lung cancer.

Current Controversies Concerning Sentinel Lymph Node Biopsy for Breast Cancer

BACKGROUND AND METHODS

The objectives of this article are to review existing controversies regarding sentinel lymph node (SLN) biopsy and to identify potential areas of consensus in order to eliminate routine axillary lymph node dissection (ALND).

RESULTS

A combination of peritumoral injection with radioisotopes and subdermal or subareolar injection with blue dye may result in enhanced success rates of SLN identification. Preoperative lymphoscintigraphy is most useful for detecting an internal mammary SLN, but the practicability of internal mammary SLN biopsy is still in the investigative stage. Intraoperative diagnosis of SLN is useful because patients with SLN metastases may be treated immediately with ALND, but it is unreasonable to expect that either examination of frozen sections or imprint cytology will detect every metastatic disease. SLN micrometastases may be of prognostic importance and these can be identified with H and E staining on permanent sections of 200 micro m intervals. While ALND is preferable for patients even with a small tumor (T1) and SLN micrometastases, radiation therapy is an acceptable alternative. SLN biopsy may be indicated for patients with DCIS detected as a palpable mass or those with large calcification areas in the breast. The accuracy of SLN biopsy after neoadjuvant chemotherapy is considered to be unproven.

CONCLUSION

Since SLN biopsy has been adopted by surgeons around the world, consistency of technique and case selection has attained great significance.

Imprint cytology of the sentinel lymph node in the assessment of axillary node status in breast carcinoma

BACKGROUND

Intra-operative assessment of the sentinel lymph node (SLN) status may allow the surgeon to complete the breast cancer surgery in most patients in one sitting. We have studied the role of imprint cytology in the assessment of SLN status.

PATIENTS AND METHODS

Imprint cytology of the SLN in 132 patients with invasive breast carcinoma was correlated with the histopathological assessment of the SLN and overall axillary nodal status. In 26 patients, the cytology was reported intra-operatively.

RESULTS

Imprint cytology reflected the status of the parent node well (sensitivity 86%, specificity 97%, positive predictive value (PPV) 92%, negative predictive value (NPV) 93%). Its ability to reflect the axillary status was also good (sensitivity 70%, specificity 97%, PPV 95% and NPV 83%) but somewhat diminished by the relatively high number of false-negative SLN in the study. Intra-operative assessment (sensitivity 86%, specificity 100%, PPV 100% and NPV 95%) did not reduce the accuracy of imprint cytology in predicting the SLN status and took a mean of 24.5 min.

CONCLUSIONS

Imprint cytology is an accurate and relatively simple method for the assessment of the SLN and can be a useful intra-operative tool.

Implication of intraoperative sentinel node imprint cytology for consent in the SNAC trial

BACKGROUND

Women randomized into the sentinel node biopsy-only arm of the Sentinel Node versus Axillary Clearance Trial require axillary clearance if the sentinel node is unable to be identified, or if the sentinel node contains metastases. The aim of the present study was to determine the likelihood of immediate and delayed axillary clearance in patients in the trial when nodes were subjected to intraoperative imprint cytology.

METHODS

A prospective database for 400 patients with operable breast cancer was analysed to determine the likelihood of lymph node involvement according to tumour size. The ability to successfully remove a sentinel node and the accuracy of intraoperative imprint cytology of sentinel nodes was investigated. These data were used to predict the likelihood of patients proceeding to immediate or delayed axillary clearance.

RESULTS

The rate of lymph node involvement was 0%, 10%, 30%, and 53% in tumours measuring <5 mm, 6-10 mm, 11-20 mm and 21-30 mm, respectively. A sentinel node was identified in 95% of cases. In a series of 79 consecutive cases using intraoperative imprint cytology, 37% of sentinel nodes containing metastases were identified intraoperatively. The estimated likelihood of undergoing immediate axillary clearance therefore ranges from 5% for tumours <5 mm, up to 24% for tumours 21-30 mm. Similarly the likelihood of delayed clearance ranges from 0% to 32% depending on tumour size.

CONCLUSIONS

It is possible to give detailed and accurate information to patients undergoing sentinel node biopsy about both the risk of lymph node involvement and the likelihood of requiring immediate or secondary axillary clearance.

Touch imprint cytology of axillary lymph nodes after neoadjuvant chemotherapy in patients with breast carcinoma

BACKGROUND

Neoadjuvant chemotherapy (NC) reportedly downstages axilla in approximately one-third of patients with locally advanced breast carcinoma (LABC). Postchemotherapy axillary lymph node status is an important prognostic factor. In the current study, the authors evaluated the reliability of touch imprint cytology (TIC) in detecting axillary lymph node metastasis after NC and identified chemotherapy-induced changes that may influence this assessment.

METHODS

Thirty-three patients with LABC were studied. Seventeen patients had received chemotherapy before surgery (NC group) and 16 patients had not (non-NC group). Touch imprints were made from either the largest axillary lymph node (in 13 patients from the NC group and 16 patients from the non-NC) or the sentinel lymph node (in 4 patients from the NC group). Imprints from the NC group were evaluated for metastasis and were correlated with histopathology. Touch imprints from both groups were compared for cellularity, tumor load, necrosis/degeneration, and histiocytes.

RESULTS

Cytologic evaluation for metastasis was 100% concordant with histopathology in all 17 patients from the NC group (9 positive results [53%] and 8 negative results [47%]). The presence of few tumor cells in sparsely cellular imprints that exhibited necrosis (two patients) and the presence of only degenerating/necrotic tumor cells (two patients) were two cytologic patterns unique to post-NC imprints that may have influenced their accurate assessment.

CONCLUSIONS

TIC was found to be reliable for the intraoperative evaluation of axillary lymph node metastasis after NC. However, a careful examination is warranted in sparsely cellular imprints, because there is the possibility of overlooking a small group of tumor cells. To the authors' knowledge, the significance of finding extensive necrosis in axillary lymph nodes after NC is not known and may be investigated.

Intraoperative imprint cytology of sentinel nodes in breast cancer

BACKGROUND AND OBJECTIVES

Sentinel node (SN) biopsy is a new standard of care for axillary node staging in patients with early-stage, clinically node-negative breast cancer. A second operation can be avoided when the results are available intraoperatively. However, there is no standard intraoperative method for SN assessment. The aim of this study was to evaluate intraoperative imprint cytology (IC) for the detection of SN involvement in patients with early-stage breast cancer.

METHODS

One hundred eighty-five consecutive patients with a breast tumor underwent SN biopsy with intraoperative IC. The SN was bisected and a touch preparation was made with a glass slide, on both sides of the cut. Permanent sections were evaluated with H&E and immunohistochemical staining. The IC results were compared with the final histologic results.

RESULTS

The sensitivity, specificity, accuracy, and positive and negative predictive values of IC were 33.3, 78.4, 78.9, 90, and 77.5%, respectively. IC was more sensitive for macrometastases than for micrometastases. In the 118 patients studied after the learning phase, 9 patients with a positive SN by IC avoided a second operation.

CONCLUSIONS

Intraoperative IC of SNs appears to be reasonably reliable in patients with breast cancer, permitting axillary dissection during the same surgical procedure when positive. In contrast, sensitivity for detection of micrometastases is low.

Touch imprint cytology and immunohistochemistry for the assessment of sentinel lymph nodes in patients with breast cancer

AIMS

Accurate evaluation of sentinel nodes is of clinical importance to avoid further surgery for axillary node dissection. A prospective study was carried out to investigate the feasibility and accuracy of touch imprint cytology (TIC) and touch imprint immunohistochemistry (TIHC).

METHODS

Two hundred and five sentinel nodes from consecutive 118 patients with primary breast cancer were studied after successful identification of sentinel nodes. Sentinel nodes were sectioned at 2 mm intervals and imprint specimens prepared from all cut surfaces were subjected to Papanicolaou staining and immunohistochemical staining using anti-cytokeratin antibody.

RESULTS

Forty-nine sentinel nodes from 40 patients were positive by permanent section. The sensitivity of TIC was 84% (41/49) per sentinel node and 83% (33/40) on a per patient basis. The sensitivity of TIHC was 86% (42/49) per sentinel node and 83% (33/40) on a per patient basis. When the results of TIC and TIHC were combined, the sensitivity was 88% (43/49) per sentinel node and 85% (34/40) on a per patient basis. Among the 156 negative sentinel nodes, four sentinel nodes from four different patients were consistently positive by TIC and TIHC, but only one patient out of 78 node-negative patients was upstaged.

CONCLUSIONS

Touch imprint cytology is sufficiently sensitive for intraoperative evaluation of sentinel nodes. A slight improvement in the sensitivity is expected when immunohistochemistry is used. The combination of these methods provides better sensitivity than either method alone.

Application of immunofluorescence for intraoperative evaluation of sentinel lymph nodes in patients with breast carcinoma

BACKGROUND

Sentinel lymph node (SLN) sampling is used to predict axillary lymph node (AxLN) metastasis in patients with breast carcinoma; AxLN sampling can be avoided in SLN-negative patients. Multistep sectioning and immunohistochemistry are reported to increase the sensitivity of micrometastasis detection. The authors used immunofluorescence (IF) staining with cytokeratin (CK) antibodies for intraoperative evaluation of touch imprints from multistep sections of SLNs.

METHODS

A combined total of 150 SLNs from 69 patients who had breast carcinoma and underwent surgery were analyzed. SLNs were sectioned at 2 mm intervals, and touch imprints subsequently were prepared. After ethanol fixation, slides were incubated with fluorescein isothiocyanate-conjugated CK and propidium iodide and then subjected to microwave irradiation for 3 minutes. Finally, fluorescence microscopy was used to evaluate slides for the presence or absence of metastatic disease.

RESULTS

Metastatic disease was identified in 36 (24.0%), 26 (17.3%), 32 (21.3%), and 31 (20.7%) of 150 lymph nodes using IF staining, Papanicolaou (Pap) staining, immunocytochemical (ICC) staining, and hematoxylin and eosin (H and E) staining, respectively. The sensitivities of IF, Pap, ICC, and H and E staining were 94.6%, 70.3%, 86.5%, and 83.8%, respectively. Except for IF staining (specificity, 99.1%), each method had a specificity of 100%. The accuracy rates for IF, Pap, ICC, and H and E staining were 98.0%, 92.7%, 96.7%, and 96.0%, respectively.

CONCLUSIONS

IF is a rapid, highly sensitive, and highly specific staining technique by which touch imprints can be used to intraoperatively evaluate SLNs in patients with breast carcinoma.

The feasibility of intraoperative diagnosis of sentinel lymph node metastases in breast cancer

BACKGROUND AND OBJECTIVES

The aim of the study was to analyse in detail the feasibility of intraoperative assessment of sentinel lymph nodes in breast cancer.

METHODS

Altogether 139 consecutive breast cancer patients with metastases in axillary sentinel nodes were included in a prospective study. A combination of imprint cytology and frozen section was used as the method of intraoperative diagnosis of sentinel node metastases. The definite postoperative evaluation of the sentinel nodes was taken as the gold standard.

RESULTS

The overall sensitivity of intraoperative diagnosis was 83%, reaching 81% if the intraoperative assessment had been limited to the two first retrieved sentinel nodes. False negative (FN) findings were more common in connection with invasive lobular carcinoma (28%) than with invasive ductal carcinoma (8%) (P < 0.01) as well as in connection with micro-metastases, in 38% of the cases, compared to the larger metastases, 6% (P < 0.00005).

CONCLUSIONS

Intraoperative examination of sentinel lymph nodes enables breast surgery, axillary staging, and treatment in the same operation in a substantial proportion of breast cancer patients. Hospital costs as well as workload in the pathology laboratory may be reduced, limiting the intraoperative assessment to the two first retrieved nodes.

Accuracy of intraoperative touch imprint cytologic analysis of sentinel lymph nodes in breast cancer

BACKGROUND

Eliminating full axillary dissection (AD) in the face of negative sentinel lymph nodes (SLN) has become increasingly popular. We sought to evaluate the accuracy of intraoperative touch imprint cytology in detecting clinically significant metastatic involvement of the SLN.

METHODS

Retrospective review of intraoperative cytology and final hematoxylin-eosin stain evaluation of sentinel nodes examined in a community hospital from 1997 to 2002.

RESULTS

During that period 1,585 patients underwent axillary dissection; 380 had SLN identification with 142 patients undergoing intraoperative cytologic evaluation of 446 SLNs. Fourteen patients with negative intraoperative cytology had involvement of a SLN on final hematoxylin-eosin examination, for a sensitivity of 75%, specificity of 100%, negative predictive value of 95%, and a false negative rate of 4.9%. In all but 1 case the metastasis was microscopic and measured 2 mm or less. Seven patients went on to completion axillary dissection (50%) with no additional nodal involvement found.

CONCLUSIONS

Intraoperative touch imprint cytology is accurate in predicting clinically significant SLN pathology. Although the false negative rate in this series was 4.9%, in all but 1 case it represented micrometastatic disease that may not necessarily require completion axillary dissection.

Touch Preparation or Frozen Section for Intraoperative Detection of Sentinel Lymph Node Metastases From Breast Cancer

BACKGROUND

The preferred technique for intraoperative evaluation of the sentinel lymph node has not been determined. The purpose of this study was to compare the sensitivity and accuracy of intraoperative evaluation of the sentinel lymph node by touch preparation cytology and frozen section.

METHODS

A total of 117 patients with clinically node-negative breast cancer or ductal carcinoma-in-situ undergoing sentinel lymph node biopsy had intraoperative evaluation of the sentinel node by touch preparation, frozen section, or both. The results of the intraoperative evaluation were compared with the final histological results of hematoxylin and eosin (H&E) paraffin section and immunohistochemistry (IHC).

RESULTS

Twenty-six (57%) of the 46 patients with nodal involvement had metastases detected during surgery. The sensitivity of touch preparation for detecting macrometastases was 78%; for detecting all H&E metastases, including micrometastases, was 57%; and for detecting all metastases, including those seen on IHC, was 40%. The sensitivity of frozen section for detecting macrometastases was 83%; for detecting all H&E metastases, including micrometastases, was 78%; and for detecting all metastases, including those seen on IHC, was 64%. Both have a low sensitivity for micrometastases seen by H&E paraffin section: 57% and 78%, respectively. Neither detected micrometastases diagnosed by IHC only.

CONCLUSIONS

Both touch preparation and frozen section seem to be accurate in detecting macrometastases, but not micrometastases. Intraoperative evaluation of the sentinel lymph node by touch preparation allows for a quick evaluation of the node without wasting significant tissue and without detecting occult microscopic metastases, which may be beneficial because the clinical importance of these has yet to be elucidated.