Evaluation of axillary sentinel lymph node biopsy by immunohistochemistry and multilevel sectioning in patients with breast carcinoma

Immunohistochemistry and Reverse Transcriptase Polymerase Chain Reaction on Sentinel Lymph Nodes can Improve the Accuracy of Nodal Staging in Breast Cancer Patients

In this study the nodal staging sensitivity of sentinel lymph node biopsy (SLNB) with detailed pathological and molecular biological examination has been investigated and compared to that of axillary lymph node dissection (ALND) with routine histological evaluation. Sentinel lymph nodes (SLNs) were removed by the dual-agent injection technique in 68 patients with primary, clinically node-negative breast cancer. Forty-seven patients had negative SLNs according to hematoxylin and eosin (H&E) staining. These H&E-negative SLNs were serially sectioned and examined at 250 μm levels by anticytokeratin immunohistochemistry (IHC). In 14 patients the SLNs were also investigated by cytokeratin 20 (CK20) reverse transcriptase polymerase chain reaction (RT-PCR). SLNB with IHC increased the node-positive rate by 26% (by 40% in tumors less than or equal to 2 cm in size (pT1) and by 9% in tumors more than 2 cm but less than or equal to 5 cm in size (pT2)). The sensitivity of SLNB with IHC was superior to that of ALND with routine histology in pT1 tumors and identical in pT2 tumors. The concordance between histology and RT-PCR was only 21%, and in two of three cases with positive histological results RT-PCR was negative. In conclusion, SLNB with detailed pathological and/or molecular biological evaluation can improve the sensitivity of regional staging. ALND can probably be abandoned in patients with pT1 SLN-negative breast cancer. Further prospective studies are required to determine the clinical significance of these detailed SLN evaluation techniques, but at present these methods are still investigational.

Nanotechnology applications in thoracic surgery

Nanotechnology is an emerging, rapidly evolving field with the potential to significantly impact care across the full spectrum of cancer therapy. Of note, several recent nanotechnological advances show particular promise to improve outcomes for thoracic surgical patients. A variety of nanotechnologies are described that offer possible solutions to existing challenges encountered in the detection, diagnosis and treatment of lung cancer. Nanotechnology-based imaging platforms have the ability to improve the surgical care of patients with thoracic malignancies through technological advances in intraoperative tumour localization, lymph node mapping and accuracy of tumour resection. Moreover, nanotechnology is poised to revolutionize adjuvant lung cancer therapy. Common chemotherapeutic drugs, such as paclitaxel, docetaxel and doxorubicin, are being formulated using various nanotechnologies to improve drug delivery, whereas nanoparticle (NP)-based imaging technologies can monitor the tumour microenvironment and facilitate molecularly targeted lung cancer therapy. Although early nanotechnology-based delivery systems show promise, the next frontier in lung cancer therapy is the development of 'theranostic' multifunctional NPs capable of integrating diagnosis, drug monitoring, tumour targeting and controlled drug release into various unifying platforms. This article provides an overview of key existing and emerging nanotechnology platforms that may find clinical application in thoracic surgery in the near future.

The sensitivity and specificity of sentinel lymph node biopsy for breast cancer at Baylor University Medical Center at Dallas: a retrospective review of 488 cases

Sentinel lymph node (SLN) biopsy has become the standard of care for breast carcinoma management, as it precludes the negative morbid effects-including decreased shoulder range of motion, lymphedema, and paresthesias-of unnecessary axillary lymph node dissection. However, the method of pathologic evaluation of the lymph node has been scrutinized to obtain the greatest sensitivity, specificity, and negative predictive value, ultimately for the benefit of the patient. This retrospective study analyzed 488 biopsies completed by two surgeons and read by multiple pathologists affiliated with Pathologists Biomedical Laboratories. When metastatic disease was not grossly obvious, analysis of the SLN began with touch imprint cytology and, if necessary, a frozen section analysis. On the subsequent day, three levels of the SLN were analyzed with hematoxylin and eosin stain and immunohistochemistry with cytokeratin AE1-3 and the appropriate control. Touch imprint cytology and/or frozen section analysis (where applicable) correctly identified 78 of 89 macrometastases, with a sensitivity of 88%, specificity of 100%, and negative predictive value of 97%. Sensitivity was 72% for micrometastases and 60% for isolated tumor cells, each with 100% specificity. In conclusion, the sensitivity and specificity of SLN biopsy at our institution compares with the higher end of percentages reported in the literature.

Detection of sentinel and non-sentinel lymph node micrometastases by complete serial sectioning and immunohistochemical analysis for gastric cancer

BACKGROUND

We investigated the presence and distribution of the sentinel and the non-sentinel node micrometastases using complete serial sectioning and immunohistochemical staining (IHC), to inspect whether lymph node micrometastases spread to the sentinel lymph nodes first.

METHODS

A total of 35 patients, who underwent gastrectomy with a sentinel lymph node biopsy for gastric cancer, were enrolled in this study. Total of 1028 lymph nodes of 35 patients having gastric cancer without metastasis of lymph node by permanent section with hematoxylin and eosin staining (H&E) were selected. There were 252 sentinel nodes and the other 776 were non-sentinel nodes. All nodes were sectioned serially and stained alternately with H&E and IHC. Lymph node micrometastases was defined as proving to be positive first either the IHC or the complete serial sectioning.

RESULTS

Micrometastases were detected in 4 (11%) of the 35 patients, 6 (0.58%) of 1028 nodes. Of these 4 patients, 3 had micrometastases exclusively in sentinel nodes, and the other had micrometastasis in both sentinel and non-sentinel nodes. There was no patient who had the micrometastases only in non-sentinel nodes.

CONCLUSION

These results support the concept that lymph node micrometastasis of gastric cancer spreads first to sentinel nodes.

Recent advances and current controversies in the management of DCIS of the breast

Ductal carcinoma in situ (DCIS) is commonly diagnosed today, mainly due to widespread use of screening mammography. Despite a better understanding of its biological behavior, many issues regarding its optimal management remain controversial. The biological behavior of DCIS has been associated with distinct molecular and histological features (such as expression of COX2, Ki67, c-erbB2, p53 mutation, presence or absence of comedonecrosis, nuclear grade, hormone receptor status, etc.). Recent advances in the diagnosis of DCIS include using magnetic resonance imaging, and the use of stereotactic-guided directional vacuum-assisted biopsy (DVAB). Ductoscopy and ductal lavage have a limited role in the management of DCIS. Surgical treatment of DCIS includes simple local excision to various forms of wider excision (segmental resection or quadrantectomy), or even mastectomy (either simple or skin-sparing). Radiotherapy following breast-conserving surgery significantly reduces local recurrence rates. Axillary lymph node dissection is not required for the management of DCIS; however, during the last decade, sentinel lymph node biopsy is increasingly used to exclude the presence of axillary metastases (when invasive disease is present within the DCIS). This approach has many advantages (including the avoidance of a second surgery if invasive disease is diagnosed within the DCIS) and should be considered when there is an increased probability for the presence of invasive breast cancer within the DCIS. The role of other minimally invasive methods (such as the "therapeutic" application of the DVAB technique, radiofrequency ablation, laser therapy, cryotherapy and brachytherapy) in the management of small DCIS remains unproven. Tamoxifen should be considered in the management of selected patients with DCIS, such as patients with hormone receptor positive DCIS, young patients, and patients without risk factors for potential side effects. Additionally, and controversial, there is evidence that aromatase inhibitors may be better than tamoxifen in the management of DCIS.

Immunocytological Detection of Lymph Node Metastases in Dogs with Malignant Epithelial Tumours

The aim of this study was to compare immunolabelling of cytological specimens with conventional staining in the detection of metastases in lymph nodes from dogs with carcinoma. Cytological touch imprints of 161 lymph nodes from 72 dogs, as well as 50 fine needle aspirates from 23 dogs, with malignant epithelial tumours were included in the study. Immunolabelling was performed with commercially available human antibodies. Touch imprints of all lymph nodes were labelled with broad spectrum anticytokeratins AE1/AE3 and KL1. In addition, lymph node touch imprints from dogs with primary tumours that reacted positively with the specific anticytokeratins CK7 (n=104) and CK20 (n=20) were also labelled with CK7 and CK20. Fine needle aspirates of 50 lymph nodes were examined by immunolabelling with AE1/AE3. "Reference investigations" with a combination of histological and immunohistochemical methods were performed on all lymph nodes. The immunocytological detection of lymph node metastases with the broad spectrum anti-cytokeratin AE1/AE3 in imprint smears resulted in a significant increase in sensitivity (0.99 vs 0.88 [conventional stain]) and in negative predictive value (0.99 vs 0.85) (P<0.01; t-test). Micrometastases in particular were detected more readily. Specificity (0.93 vs 0.88) and positive predictive value (0.95 vs 0.90) did not differ significantly between the two techniques. Immunolabelling with KL1 was associated with lower sensitivity and negative predictive value, indicating lack of cross-reactivity of this antibody with canine epithelial cells. In fine needle aspirates the detection of lymph node metastases, especially micrometastases, was more efficient by mean of immunolabelling with AE1/AE3 than by conventional staining. The study indicated the value of immunocytological labelling for the detection of metastases in cytological specimens of canine lymph node preparations.

Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review

Ductal carcinoma in situ (DCIS) of the breast is defined as a proliferation of malignant epithelial cells within breast ducts without evidence of invasion through the basement membrane. The detection rate of DCIS of the breast has dramatically increased since the mid-1980s as the result of the widespread use of screening mammography. DCIS currently represents about 15-25% of all breast cancers detected in population screening programmes. Although inherently a non-invasive disease, occult invasion with the potential of lymph node metastases may occur. Where performing an axillary lymph node dissection-or-not for DCIS used to be an important dilemma, the same now holds for the sentinel node biopsy. This article reviews the potential role of the sentinel node biopsy (SNB) in patients with DCIS. We conclude that based on the current literature, there is in general no role for a SNB in DCIS. A SNB should only be considered in patients with an excisional biopsy diagnosis of high risk DCIS (grade III with palpable mass or large tumour area by imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS, although SNB may be contraindicated in many of the latter patients because of lesion size and/or multifocality. Even in these patients the value of a positive SN, containing mostly isolated tumour cells, is questionable.

Intraoperative evaluation of sentinel lymph nodes for metastatic melanoma by imprint cytology

BACKGROUND

Sentinel lymph node biopsy (SLN) has revolutionized nodal staging. Accurate intraoperative evaluation of SLN permits a single procedure, with lymphadenectomy being performed during the initial operative procedure when the SLN is positive. There is a paucity of literature on intraoperative imprint cytology (IIC) evaluation of the SLN in melanoma. The purpose of this article is to present an update to our experience with IIC for SLN in melanoma.

METHODS

Melanoma patients had SLNs examined by IIC. SLNs were bisected, and imprints were made from each half. Imprints were stained with hematoxylin and eosin and with Diff-Quik. Paraffin-embedded sections were examined with multiple hematoxylin and eosin-stained sections from the SLNs in conjunction with immunohistochemical staining for S-100, Melan-A, and HMB-45 proteins.

RESULTS

Metastases were identified in 40 (17%) of 229 patients. Of these, 13 patients were detected by IIC (sensitivity, 33%). The negative predictive value was 88%. No false-positive results were identified (specificity, 100%). The positive predictive value was 100%. The accuracy of IIC was 78%. The sensitivity for detecting macrometastases (>2 mm) was better than that for detecting micrometastases (< or =2 mm): 62% vs. 16% (P < .01). Patients with positive SLNs by IIC had lymphadenectomy under the same anesthetic. A total of 533 nonsentinel lymph nodes were identified in 42 patients. Only two patients (8%) had positive nonsentinel lymph nodes after a negative IIC.

CONCLUSIONS

IIC is a viable alternative to frozen sectioning when intraoperative evaluation is desired. IIC is significantly more sensitive for macrometastases. IIC evaluation of SLNs in melanoma makes a single operative procedure possible for a significant proportion of patients with regional nodal metastases.

Comprehensive examination of sentinel lymph node in breast cancer: a solution without a problem?

Although several methods have been devised to examine sentinel lymph node (SLN) specimens in breast cancer, the extent of examination and whether it should routinely include multilevel sectioning to detect micrometastases (MM) (<2.0 mm) is still debated. In this study all "positive'' SLN biopsies from 67 consecutive patients with breast carcinoma and evaluated by means of an extended protocol were reviewed. Abnormal findings included micrometastases (MM) between 0.2 and 1.0 mm (14 cases), (MM) between 1.0 and 2.0 mm (8 cases), metastases>2.0 mm (22 cases), and isolated tumor cells (ITCs) (23 cases). The likelihood of finding metastatic deposits was comparable if sections were carried out at 100-, 150-, 200-, 250-, and 500-microm intervals. No metastatic foci>2.0 mm would have been missed. 1 MM (1.1 mm focus) was missed within the 250- and 500-microm levels on hematoxylin-eosin, but not complementary cytokeratin staining. Our data show that SLN step sectioning does not add significant yield if compared to standard examination carried on initial levels, if the minimal target of 1.0 mm micrometastatic deposit is sought.

Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis

BACKGROUND

Lymphatic mapping with sentinel lymph node biopsy has the potential for reducing the morbidity associated with breast carcinoma staging. It has become a widely used technology despite limited data from controlled clinical trials.

METHODS

A systematic review of the world's literature of sentinel lymph node (SLN) biopsy in patients with early-stage breast carcinoma was undertaken by using electronic and hand searching techniques. Only studies that incorporated full axillary lymph node dissection (ALND), regardless of SLN results, were included. Individual study results along with weighted summary measures were estimated using the Mantel-Haenszel method. The correlations of outcomes with the study size, the proportion of positive lymph nodes, the technique used, and the study quality were evaluated.

RESULTS

Between 1970 and 2003, 69 trials were reported that met eligibility criteria. Of the 8059 patients who were studied, 7765 patients (96%) had successfully mapped SLNs. The proportion of patients who had successfully mapped SLNs ranged from 41% to 100%, with > 50% of studies reporting a rate < 90%. Lymph node involvement was found in 3132 patients (42%) and ranged from 17% to 74% across studies. The false-negative rate (FNR) ranged from 0% to 29%, averaging 7.3% overall. Eleven trials (15.9%) reported an FNR of 0.0, whereas 26 trials (37.7%) reported an FNR > 10%. Significant inverse correlations were observed between the FNR and both the number of patients studied (r = - 0.42; P < 0.01) and the proportion of patients who had successfully mapped SLNs nodes (r = - 0.32; P = 0.009).

CONCLUSIONS

Lymphatic mapping with SLN biopsy is used widely to reduce the complications associated with ALND in patients with low-risk breast carcinoma. This systematic review revealed a wide variation in test performance.

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.

Prognostic relevance of occult tumour cells in lymph nodes in colorectal cancer

AIMS

Presently, in Europe the treatment of node-negative colorectal cancer (CRC) patients consists of surgical resection of the primary tumour without adjuvant systemic therapy. However, up to 30% of these patients will develop disease recurrence. These high-risk patients are possibly identified by occult tumour cell (OTC) assessment in lymph nodes. In this paper, studies on the clinical relevance of OTC in lymph nodes are reviewed.

METHODS

A literature search was conducted in the National Library of Medicine by using the keywords colonic, rectal, colorectal, neoplasm, adenocarcinoma, cancer, lymph node, polymerase chain reaction, mRNA, immunohistochemistry, micrometastases and isolated tumour cells. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

RESULTS

The upstaging percentages through OTC assessment and the prognostic relevance of OTC in lymph nodes vary among studies, which is related to differences in techniques used to detect OTC.

CONCLUSIONS

We conclude that OTC examination techniques should be standardized to illuminate whether OTC in lymph nodes can reliably identify high-risk node-negative patients.

Additional axillary metastases and stage migration in breast cancer patients with micrometastases or submicrometastases in sentinel lymph nodes

BACKGROUND

In patients with breast cancer, micrometastases and submicrometastases are increasingly found in sentinel nodes when step sectioning and/or immunohistochemical staining are applied. The aims of the current study were to investigate the incidence of micro- and submicrometastases in the sentinel node, to estimate the risk of additional metastases in the remaining axillary lymph nodes, and to consider implications for staging and treatment.

METHODS

A total of 2150 breast cancer patients who had undergone axillary sentinel node biopsy between 1999 and 2004 were retrospectively evaluated.

RESULTS

In all, 649 patients (30%) had a tumor-positive axillary sentinel node. Of these 649 patients, 148 had (23%) micrometastases and 105 (16%) submicrometastases. Of the 148 patients with micrometastases, 106 underwent axillary lymph node dissection (ALND) and additional metastases were found in 20 patients (19%). Sixteen (15%) had macrometastases and were upstaged. The other 4 patients had additional micrometastases. Seven of the 106 patients (7%) received additional systemic treatment based on the findings in the axillary lymph nodes. Fifty-four of the 105 patients with submicrometastases underwent ALND. Two (4%) of them had additional macrometastases and were upstaged and 2 had additional micrometastases. None received additional treatment based on the ALND findings.

CONCLUSIONS

Of the involved sentinel nodes, 23% contained micrometastases and 16% submicrometastases. Additional macrometastases were found in 15% and 4%, respectively, and treatment was altered in 7%. Based on these findings, offering additional treatment of the axilla is suggested in patients with micrometastases, but refraining from ALND in patients with submicrometastases in their sentinel node.

Potential of magnetic resonance spectroscopy to detect metastasis in axillary lymph nodes in breast cancer

Focused pathological evaluation of axillary lymph nodes in breast cancer is gaining importance. Nuclear magnetic resonance (NMR) spectroscopy that assesses the whole of the specimen has the potential in evaluating micrometastases. The biochemical changes associated with breast cancer metastases in axillary nodes by in vitro NMR and its use in the detection of axillary metastases in a clinical setting in comparison with conventional histopathology is presented in this study. Eighty-eight lymph nodes obtained from 30 patients with breast cancer were investigated. Histopathology revealed metastases in 20 nodes from 11 patients, while in vitro NMR spectroscopy revealed metastases in 22 nodes. Out of these 22 nodes, 16 were the same, which showed metastases on histopathology, while 6 nodes have shown metastases only on in vitro magnetic resonance spectroscopy (MRS). These 6 nodes with suspicion of metastases on MRS were subjected to reevaluation with serial sectioning and immunohistochemistry, but no additional metastases were revealed. Forty metabolites could be identified from the MR spectrum of lymph nodes. The levels of the glycerophosphocholine-phosphocholine (GPC-PC), choline, lactate, alanine and uridine diphosphoglucose were elevated significantly in nodes with metastases. In addition, the intensity ratio of GPC-PC/threonine (Thr) was higher in nodes with metastases, and using this as marker, MRS detected the axillary metastases with a sensitivity, specificity and accuracy of 80%, 91% and 88%, respectively. Neoadjuvant chemotherapy (NACT) lowered the concentrations of GPC-PC and GPC-PC/Thr ratio. The accuracy of MRS in detecting metastases was 75% in patients who received NACT (n=9) as compared to 96% in those who did not (n=21). Our results demonstrate the potential of in vitro MRS in characterizing the metabolite profile of the axillary nodes with breast cancer metastases. It detected axillary metastases with reasonable accuracy and can be complementary to histopathological evaluation and immunohistochemistry.

Circulating tumor cells in patients with breast cancer: possible predictor of micro-metastasis in bone marrow but not in sentinel lymph nodes

BACKGROUND

Blood and lymphatic circulation are the major routes during metastatic spread of breast cancer cells. Despite the predictive and prognostic value of bone marrow (BM) micro-metastasis, repeated and frequent BM aspirations may not be easily accepted by patients. We try to establish the role of circulating tumor cells as a predictor for micro-metastasis in BM and sentinel lymph node (SLN) as well as to identify the association between micro-metastasis in blood and lymphatic circulation. We prospectively studied 47 breast cancer patients without overt metastasis. Bilateral BM samples and blood samples were obtained before surgery and subsequently handled using magnetic-activated cell separation (MACS) followed by immunocytochemistry (ICC). SLN was examined by hematoxylin and eosin (H and E) staining and ICC.

RESULTS

Blood and BM micro-metastasis were detected in 16 (35%) and 25 (54%) of 47 patients. SLN micro-metastasis were detected in 13 (27.7%) and 22 (46.8%) patients using H and E and ICC, respectively. All the patients with circulating tumor cells had micro-metastasis in BM, whereas 9 of 25 (36%) patients with micro-metastasis in BM had no circulating tumor cells (P < 0.001). On the other hand, there is no correlation between circulating tumor cells and micro-metastasis in SLNs detected by either H and E (P = 0.52) or ICC (P = 0.36). We found that the presence of circulating tumor cells might predict BM micro-metastasis but not SLN micro-metastasis. It is also interesting to find that the presence of SLN micro-metastasis does not necessarily correlate with the presence of micro-metastasis in BM and blood.

The reliability and accuracy of intraoperative imprint cytology of sentinel lymph nodes in breast cancer

OBJECTIVE

Sentinel lymph node (SLN) biopsy is a new component of the surgical treatment of breast cancer that accurately predicts axillary status. In this study the authors evaluated the accuracy of intraoperative imprint cytology (IC) in comparison with definitive histologic evaluation of SLN in breast cancer patients.

METHODS

A total 413 women with breast carcinoma and clinically negative axillary nodes underwent breast surgery and SLN biopsy. Mapping of SLN involved injection of (99m)Technecium labelled human albumin nanocolloid particles and Patent Blue dye. At the Department of Pathology, SLNs were bisected along its major axis. Both halves were imprinted 2-4 times on the slides and immediate staining with Hemacolor (Merck Germany) was performed for intraoperative examination. Imprint node negative women underwent no further surgery, while node positive women proceeded to full axillary clearance. Histological analysis of the SLN involved serial sectioning of the whole node with H&E and immunostaining for cytokeratin.

RESULTS

Definitive histology revealed metastases (pN+) in 159/413 patients (38.5%): 69 (16.7%) macro metastases, 57 (13.8%) micro metastases, and 33 (8%) women with only isolated IHC positive cells or positive cell groups smaller than 0.2 mm (pNO sn+). The other 254 women had negative SLN biopsy. Imprint cytology detected 54/69 macro metastases, and 4/57 micro metastases. In the group with negative SLN (254), 2 cases were ''false positives''.

CONCLUSIONS

Imprint of SLN biopsy can identify a negative axilla with high accuracy (specificity 99.2%). Overall sensitivity is only 36.5%, but macrometastases are detected in 77% which is important for performing ALDN in one session with operation of primary tumour.

5-Year Follow-up after Sentinel Node Mapping for Breast Cancer Demonstrates Better than Expected Treatment Outcomes

We conducted this study to provide one of the initial assessments of treatment outcomes for breast cancer patients evaluated with sentinel node mapping. All patients diagnosed with breast carcinoma, evaluated with sentinel node mapping, and followed for 5 years were divided into three groups depending on sentinel node(s) status. Group I (node negative) included 91 patients, 77 with invasive cancer, and 7 lost to follow-up. Of the remaining 70 patients, 3 (4.3%) suffered a distant recurrence and died, 1 developed an in-breast recurrence, and 9 (12.9%) developed a contralateral cancer during the study. Group II (IHC positive) included 28 patients. One (3.6%) developed a distant recurrence and died of breast cancer, and one developed a contralateral cancer during follow. Group III (H&E positive) included 36 patients with 1 lost to follow-up. Five patients (14.3%) died of breast cancer and two (5.7%) developed contralateral carcinomas during follow-up. The most striking observation was a lower than expected rate of distant recurrences in these patients followed for 5 years after a diagnosis of breast cancer and staging with sentinel node mapping. The ability to identify subtle nodal metastasis and design appropriate systemic therapeutic strategies may explain this finding.

Clinical outcome of patients with lymph node-negative breast carcinoma who have sentinel lymph node micrometastases detected by immunohistochemistry

BACKGROUND

The ideal pathologic assessment of sentinel lymph nodes (SLNs) in patients with breast carcinoma remains controversial. The authors evaluated how detailed assessment of SLNs using immunohistochemistry (IHC) and serial sectioning would affect treatment decisions and outcomes in patients with breast carcinoma who had negative SLNs on standard hematoxylin and eosin staining.

METHODS

The SLNs from patients who were treated between June 1998 and June, 1999 and who had negative lymph node status determined by hematoxylin and eosin staining (n = 84 patients) were evaluated further with serial sectioning and cytokeratin IHC. Patients were offered adjuvant therapy based on primary tumor factors.

RESULTS

The median patient age was 57 years, and the median tumor size was 1.2 cm. At a median follow-up of 40.2 months, 81 patients (96%) were alive with no evidence of disease, 1 patient was alive with disease, 1 patient had died of disease, and 1 patient had died of other causes. Fifteen patients (18%) had micrometastases identified on IHC. Of the total 84 patients, information regarding adjuvant therapy was not available for 5 patients. Of the remaining 79 patients, 10 patients (13%) were not offered adjuvant chemotherapy but had positive SLN status determined by IHC. SLN status based on IHC evaluation did not correlate with age (P = 0.077), tumor size (P = 0.717), grade (P = 0.148), estrogen receptor status (P = 1.000), or lymphovascular invasion (P = 0.274). Furthermore, IHC-detected positive SLN status did not correlate with distant metastasis (P = 0.372) or overall or distant metastasis-free survival (P = 0.543 and P = 0.540, respectively).

CONCLUSIONS

Although the finding of SLN micrometastases by IHC may change management in > 12% of patients, preliminary results suggested that such micrometastases do not affect outcomes significantly.

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 frozen section examination of axillary sentinel lymph nodes in breast cancer

The study presents the results from intraoperative frozen section assessment of axillary sentinel lymph nodes (SLNs) in breast cancer. Routine histological frozen sections from one level were used, two sections stained with haematoxylin and eosin. Immunohistochemistry for cytokeratins was applied to the permanent SLN paraffin sections only. Axillary dissection was performed on all SLN-positive cases regardless of the size of the metastatic deposits. With a detection rate of 83%, 272 patients entered the study over a period of 46 months. A total of 61 cases were SLN positive by frozen section analysis. The paraffin sections gave an additional 23 SLN-positive cases. The false-negative rate for frozen sections was then 27% (23/84). Micrometastases were found in 28 of 84 cases, and macrometastases in 56. The false-negative rate of frozen sections for micrometastases was 71% (20/28), and for macrometastases 5% (3/56). A total of 73% (61/84) of the patients underwent axillary surgery as a one-step procedure.

Sentinel Lymph Node Biopsy or Detection of Micrometastasis in Bone Marrow: Which Might Be an Alternative to Axillary Lymph Node Dissection in Breast Cancer Patients?

Axillary lymph node status has limited prognostic significance in breast cancer patients and much improvement can be made. Sentinel lymph node biopsy is emerging as an alternative to axillary lymph node dissection for staging, but its prognostic relevance is still uncertain. Detection of micrometastases in sentinel nodes and bone marrow may provide more information, but the clinical significance still needs to be confirmed by ongoing large trials. In this review, we focus on the possibility of sentinel lymph node biopsy or detection of bone marrow micrometastasis replacing traditional axillary lymph node dissection.

Supervised automated microscopy increases sensitivity and efficiency of detection of sentinel node micrometastases in patients with breast cancer

AIMS

To investigate the practicality and sensitivity of supervised automated microscopy (AM) for the detection of micrometastasis in sentinel lymph nodes (SLNs) from patients with breast carcinoma.

METHODS

In total, 440 SLN slides (immunohistochemically stained for cytokeratin) from 86 patients were obtained from two hospitals. Samples were selected on the basis of: (1) a pathology report mentioning micrometastases or isolated tumour cells (ITCs) and (2) reported as negative nodes (N0).

RESULTS

From a test set of 29 slides (12 SLN positive patients, including positive and negative nodes), 18 slides were scored positive by supervised AM and 11 were negative. Routine examination revealed 17 positive slides and 12 negative. Subsequently, automated reanalysis of 187 slides (34 patients; institute I) and 216 slides (40 patients; institute II) from reported node negative (N0) patients showed that two and seven slides (from two and five patients, respectively) contained ITCs, respectively, all confirmed by the pathologists, corresponding to 5.9% and 12.5% missed patients. In four of the seven missed cases from institute II, AM also detected clusters of four to 30 cells, but all with a size < or = 0.2 mm.

CONCLUSIONS

Supervised AM is a more sensitive method for detecting immunohistochemically stained micrometastasis and ITCs in SLNs than routine pathology. However, the clinical relevance of detecting cytokeratin positive cells in SLNs of patients with breast cancer is still an unresolved issue and is at the moment being validated in larger clinical trials.

Intraoperative cytologic examination of breast sentinel lymph nodes: test utility and patient impact

The sentinel lymph node (SLN) procedure is a method for ascertaining the axillary lymph node status in patients with breast cancer. Intraoperative examination of the SLN may be important, because a positive result directs surgery to a complete axillary lymph node dissection. Intraoperative cytologic examination (IOCE) is a method of intraoperative evaluation, although little data are available regarding the sensitivity of the method with respect to tumor size and the size of the SLN metastasis. All SLN cases for the years 1997-2002 at Magee-Womens Hospital were tabulated for primary breast carcinoma size, IOCE result, final histologic result, and size of the SLN metastasis. All SLNs had IOCE with touch imprints. Scrape SLN preparations and frozen sections were strongly discouraged. There were 748 SLN cases comprising 1576 SLNs that had IOCE, and there were 247 true positive SLN cases comprising 522 SLNs. Of the 247 true positive SLN cases, 111 had a positive IOCE (111/247; 45% sensitivity overall) and there were 136 false negatives. Of the 247 cases, 164 were SLN micrometastases < or =2.0 mm in size, and 44 (27%) of these were detected by IOCE, while the remaining 120 cases were false negative. Of the 83 SLN macrometastases (>2.0 mm), 66 (80%) were detected by IOCE, with 17 false negatives. In this series, 15 cases (2%) were given the IOCE diagnosis of atypical/defer, and all of these permanent sections were histologically positive. There were five IOCE-positive cases that were histologically negative. Of the 164 SLNs with micrometastases < or =2.0 mm, 17.6% (29/164) were < or =0.5 mm (6/29 [21.4%] were IOCE positive), 5.5% (9/164) were 0.51-1.0 mm (3/9 [33%] were IOCE positive), and 3.6% (6/164) were 1.1-2.0 mm (2/6 [33%] were IOCE positive). There were 83 SLNs with macrometastases larger than 2.0 mm, and 66/83 (80%) were detected by IOCE. In this group, 22% (18/83) were 2.1-5.0 mm (8/18 [44.4%] were IOCE positive) and 57.8% (48/83) were larger than 5.0 mm (41/48 [85%] were IOCE positive). The mean primary breast tumor size was 15.4 mm, with a mean SLN tumor size of 1.4 mm. There was a significant correlation with tumor size and the presence of SLN metastasis, and a significant correlation with tumor size and size of the SLN metastasis. There was a significant t correlation of primary tumor size and positive IOCE, with the group of negative IOCE cases having a mean tumor size of 14 mm and the positive IOCE group having a mean tumor size of 22 mm. The overall sensitivity of the method was 45%, specificity 99%, positive predictive value 0.99, and negative predictive value 0.80. Sensitivity of the IOCE procedure based on SLN tumor size is as follows: < or =0.5 mm, 21.4%; 0.51-1.0 mm, 33%; 1.1-2.0 mm, 33%; 2.1-5.0 mm, 44.4%; and >5.0 mm, 85%. Primary tumor size correlates with a positive SLN status and size of the SLN metastasis. Most false-negative IOCEs are due to micrometastases. Positive IOCE cases had a significantly larger SLN metastasis size (mean 8.0 mm) than the false-negative IOCE group (mean 1.4 mm). The IOCE of SLNs has a high negative predictive value, but this is a poor test for the detection of micrometastases, as this group accounts for the majority of false-negative IOCEs of breast SLNs.

Sentinel Lymph Node Micrometastasis as a Predictor of Axillary Tumor Burden

The sentinel lymph node biopsy (SLNB) procedure is an alternative method for assessing the axillary lymph node (ALN) status in patients with breast cancer. The SLNB carries the risk of a false-negative result, with patients harboring positive ALNs in the face of a negative SLNB examination. In addition, the significance of a SLNB with cells identified only with keratin or with deposits less than 0.2 mm remains unresolved. We analyzed our SLNB data over the past 5 years in order to determine the relationship between SLN tumor burden and ALN tumor burden. Pathology files for the past 5 years at Magee-Womens Hospital were searched for all SLNB cases that had an axillary lymph node dissection (ALND). Each SLNB case was reviewed and tabulated for breast tumor size, SLN tumor size, and largest tumor size in the ALND. Correlation and frequency distribution were performed for the status of all SLNs and ALNDs. Patterns of lymph node metastasis were recorded and the sizes of the SLN metastases were reported according to the recent Philadelphia Consensus Conference on Sentinel Lymph Nodes and the revised American Joint Committee on Cancer (AJCC) staging. SLN metastases were classified as immunohistochemistry (IHC) positive if only single keratin-positive cells or clusters were present and were not observed with standard tissue stains, as submicrometastatic (SMM) if tumors were less than 0.2 mm (excluding IHC positive), as micrometastatic if tumors were larger than 0.2 mm but </=2 mm, or as macrometastatic if tumors were larger than 2 mm. A total of 445 patients had both SLNB and ALND. Fifty percent (224/445) of cases were SLN positive, including 58 SLN positive/ALN positive cases and 166 SLN positive/ALN negative cases. Of the 221 patients in the SLN-negative group, 4 were ALN positive (false-negative SLN). The incidence of SLN metastases increased with tumor stage, with the percentage of SLN positives as follows: T1a, 2.1%; T1b, 10.9%; T1c, 51.7%; and T2, 35.3%. There were 4 of 41 patients (10%) with SLNs that were IHC positive that had macrometastases in a solitary ALN. Three of 22 patients (13.6%) that were SMM positive had ALN macrometastasis in a solitary ALN. Four of 49 patients (8.1%) with micrometastatic SLNs had a solitary positive ALN, 3 of which were macrometastases (6.1%). Overall a total of 10 of 112 patients (9.0%) with traditionally defined SLN micrometastases of 2.0 mm or less had a solitary ALN macrometastasis. The vast majority (90%) of these macrometastases were found with T1c and T2 breast tumors. There was a significant difference in the means of SLN tumor sizes for the SLN-positive/ALND-negative (4.5 mm) versus SLN-positive/ALND-positive (10.1 mm) patients, although the range of SLN tumor sizes within each group were similar. There is an increasing incidence of SLN-positive and ALN-positive cases with increasing T stage. Overall in this series, 9% of patients with SLN metastases </=2 mm had a solitary axillary macrometastasis. Ninety percent of these metastases occurred with T1c/T2 breast tumors, indicating the important codependence of T stage. Overall there is a subset of patients who are IHC positive, SMM positive, or micrometastatic positive with ALNs that are macrometastatic who are at risk of harboring axillary macrometastases. Keratin IHC of breast SLNs is useful for defining these subsets.

Intraoperative imprint cytologic evaluation of sentinel lymph nodes for lobular carcinoma of the breast

BACKGROUND

The evaluation of sentinel lymph nodes (SLNs) from a woman with lobular cancer of the breast is frequently challenging. Intraoperative imprint cytology (IIC) is equivalent to frozen sectioning for rapid SLN evaluation and is advantageous because it is rapid, reliable, cost-effective, and conserves tissue. Metastatic lobular carcinoma is difficult to identify in SLN because of its low-grade cytomorphology, its tendency to infiltrate lymph nodes in a single cell pattern, and because individual cells can resemble lymphocytes. We are unaware of any large published studies, using any technique, to evaluate SLN for lobular carcinoma.

METHODS

A retrospective review of the intraoperative imprint cytology results of 678 SLN mapping procedures for breast carcinoma was performed. From this cohort, we studied SLN from cases of lobular carcinoma. These SLN were evaluated intraoperatively by either bisecting or slicing the SLN into 4-mm sections. Imprints were made of each cut surface and stained with hematoxylin and eosin and/or Diff-Quik. Permanent sections were evaluated with up to 4 hematoxylin and eosin-stained levels and cytokeratin immunohistochemistry. IIC results were compared with final histologic results.

RESULTS

Sixty-one cases of pure invasive lobular carcinoma were identified. Sensitivity was 52%, specificity was 100%, accuracy was 82%, negative predictive value was 78%. No statistically significant differences in sensitivity, specificity or accuracy were identified for the intraoperative detection of lobular carcinoma versus ductal carcinoma. The sensitivity for detecting macrometastases (more than 2 mm) was better than for detecting micrometastases, 73 versus 25%, respectively (P = 0.059).

CONCLUSIONS

The sensitivity and specificity of IIC are similar to that of intraoperative frozen section evaluation. Therefore, IIC is a viable alternative to frozen sectioning when intraoperative evaluation is required. If SLN micrometastasis is used to determine the need for further lymphadenectomy, more sensitive intraoperative methods will be needed to avoid a second operation.

Pathological work-up of sentinel lymph nodes in breast cancer. Review of current data to be considered for the formulation of guidelines

Controversies and inconsistencies regarding the pathological work-up of sentinel lymph nodes (SNs) led the European Working Group for Breast Screening Pathology (EWGBSP) to review published data and current evidence that can promote the formulation of European guidelines for the pathological work-up of SNs. After an evaluation of the accuracy of SN biopsy as a staging procedure, the yields of different sectioning methods and the immunohistochemical detection of metastatic cells are reviewed. Currently published data do not allow the significance of micrometastases or isolated tumour cells to be established, but it is suggested that approximately 18% of the cases may be associated with further nodal (non-SN) metastases, i.e. approximately 2% of all patients initially staged by SN biopsy. The methods for the intraoperative and molecular assessment of SNs are also surveyed.

Rapid immunohistochemistry for cytokeratin in the intraoperative evaluation of sentinel lymph nodes for metastatic breast carcinoma

The sensitivity and specificity of detecting metastatic breast carcinoma in sentinel lymph nodes using a rapid immunohistochemistry technique was determined and compared with methods currently used at the authors' institution. At the time of intraoperative consultation, after routine diagnostic touch preparations and frozen sections were prepared, 6-microm frozen sections of 72 sentinel lymph nodes from 32 patients with breast carcinoma were placed on plus slides, fixed in cold acetone for 2 or 3 minutes, and stored at -70 degrees C. These sections were immunostained with a prediluted broad-spectrum anticytokeratin monoclonal antibody coupled to an inert polymer with horseradish peroxidase (DAKO EPOS). Slides were ready for interpretation within 16 minutes and were scored as positive, negative, or equivocal for metastatic carcinoma. Results were compared with those of the intraoperative touch preparations and frozen sections and with paraffin-embedded, hematoxylin and eosin-stained, and AE1/AE3 immunostained permanent sections. Fourteen (19%) sentinel lymph nodes were positive for metastatic carcinoma in 13 patients. All methods tested were 100% specific. The rapid immunohistochemistry method was the least sensitive (57% sensitivity) of all methods used to detect metastasis. Routine diagnostic touch preparations, frozen sections, and permanent sections had sensitivities of 69%, 86%, and 100% respectively. In conclusion, this rapid immunohistochemistry method would not be helpful in intraoperative assessment of sentinel lymph nodes in breast cancer patients due to its low sensitivity.

Histologic localization of sentinel lymph node metastases in breast cancer

Data from a recent study support the hypothesis that axillary lymph node metastases frequently localize near the inflow junction of the afferent lymphatic vessel. Our goal was to evaluate the microscopic location of axillary sentinel lymph node metastases in a prospective study of breast cancer patients. A total of 305 axillary sentinel lymph nodes from 213 breast cancer patients undergoing surgery at our institution were evaluated. Preoperative lymphoscintigraphy using technetium-labeled sulfur colloid and intraoperative isosulfan blue dye injection were used for identifying the sentinel lymph node. Intraoperatively, the surgeon placed a suture either at the point of entry of isosulfan blue dye or at the area with the highest radioactive counts, and this area was inked at the grossing bench before processing. Metastases were identified in 55 of the 305 lymph nodes examined. Thirty-four nodes contained metastases in both the inked half and the opposite half. Metastatic tumor was identified in the inked half alone in 18 lymph nodes. Only three nodes contained metastatic tumor in the opposite half with no tumor in the inked half (p <0.001). Similar results were found when nodes tagged at the point of blue dye entry and nodes tagged at the area with the highest radioactive counts were analyzed separately. Our findings suggest that metastatic tumor has a higher probability of being present in the region of the inflow junction of the afferent lymphatic vessel. This information may be useful in determining the optimal method for evaluating axillary sentinel lymph node specimens from breast cancer patients.

Complete sectioning of axillary sentinel nodes in patients with breast cancer. Analysis of two different step sectioning and immunohistochemistry protocols in 246 patients

AIMS

To evaluate two detailed step sectioning protocols for sentinel lymph nodes (SLNs).

METHODS

After vital dye or combined dye and radiocolloid guided biopsy, SLNs were fixed in formalin and embedded in paraffin wax. In protocol A, SLNs from 123 patients were sectioned in steps of 50-100 micro m, whereas in protocol B, SLNs from 123 patients were sectioned at steps of 250 micro m. Epithelial marker immunohistochemistry (IHC) was performed on multiple levels in cases with negative haematoxylin and eosin findings.

RESULTS

In groups A and B, 74 and 47 patients were found to have tumour cells in their axillary SLNs, and 19 (28%) and 18 (19%) patients, respectively, were upstaged as compared with the standard histological assessment. Nodal involvement detected by deeper sections was often micrometastatic or in isolated tumour cells

CONCLUSIONS

Serial sectioning and IHC are recommended for the evaluation of SLNs. The optimal extent of the histopathological work up should be studied further.

Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes

BACKGROUND AND METHODS

This review examines the various methods of detecting occult breast cancer metastasis in the sentinel lymph node (SLN). The prognostic relevance of such micrometastases and isolated tumour cells, and their impact on stage migration and decision making with respect to axillary dissection and adjuvant systemic therapy, are discussed.

RESULTS

Examination of SLNs by serial section with haematoxylin and eosin and/or immuno histochemical staining significantly increases the detection rate of micrometastases, even in patients with very small (T1) tumours. However, the prognostic relevance of isolated tumour cells and small micrometastases is uncertain. Moreover, deciding which patients might benefit from axillary dissection is complicated by the fact that adjuvant radiotherapy and systemic chemotherapy alone may eradicate most micrometastases.

CONCLUSION

Ongoing randomized trials comparing the results of SLN biopsy alone with those of axillary dissection should answer the question of whether isolated tumour cells and small micrometastases are clinically relevant. This should also indicate which patients with SLN micrometastasis are likely to benefit from axillary dissection. In this sense, SLN biopsy must be considered still to be at an investigative stage; outwith clinical trials complete axillary dissection should be performed on all patients with SLN micrometastasis.

Immunohistochemical evaluation of sentinel lymph nodes in breast carcinoma patients

Sentinel lymph node sampling has become an alternative to axillary lymph node dissection to provide prognostic and treatment information in breast cancer patients. The role of immunohistochemistry has yet to be established. A total of 241 sentinel lymph nodes (in 270 slides) from 91 patients with invasive carcinoma (73 ductal, 9 lobular, 8 mixed lobular/ductal, 1 NOS) were studied for presence of macrometastases (> 0.2 cm), identified in hematoxylin and eosin sections, and occult metastases (micrometastases [< or = 0.2 cm], clusters of cells, isolated carcinoma cells), identified only by immunohistochemistry. Intraoperative touch preparations, frozen sections, seven hematoxylin and eosin levels (L1-L7), and two AE1-3 cytokeratin immunohistochemistries (L1, L4-5) of the entire bisected or trisected sentinel lymph node were examined. Thirty-one (34%) patients had 50 positive sentinel lymph nodes. Twenty-six (33%) sentinel lymph nodes had metastatic carcinoma (11 macrometastases, 11 micrometastases, 3 clusters of cells, 1 isolated carcinoma cells) by touch preparations, frozen sections, and one hematoxylin and eosin (L1). Thirty-eight (43%) were positive by AE1-3 immunohistochemistry (L1) (11 macrometastases, 8 micrometastases, 13 clusters of cells, 6 isolated carcinoma cells), significantly more than by touch preparations, frozen sections, hematoxylin and eosin L1, or hematoxylin and eosin L2-7. Cytokeratin immunostain on L4-5 demonstrated 31 (34%) positive sentinel lymph nodes, a similar frequency to cytokeratin immunostain on L1. Size of sentinel lymph node metastasis did not correlate with size, histologic grade, or type of primary breast carcinoma. AE1-3 (L1) immunohistochemistry is highly sensitive in delineating sentinel lymph node metastasis, especially clusters of cells and isolated carcinoma cells. The prognostic significance of clusters of cells and isolated carcinoma cells and the value of AE1-3 immunohistochemistry on frozen sections need to be determined.

Intraoperative analysis of sentinel lymph nodes by imprint cytology for cancer of the breast

BACKGROUND

The utilization of lymphatic mapping techniques for breast carcinoma has made intraoperative evaluation of sentinel lymph nodes (SLN) attractive, because axillary lymph node dissection can be performed during the initial surgery if the SLN is positive. The optimal technique for rapid SLN assessment has not been determined. Both frozen sectioning and imprint cytology are used for rapid intraoperative SLN evaluation.

METHODS

A retrospective review of the intraoperative imprint cytology results of 133 SLN mapping procedures from 132 breast carcinoma patients was performed. SLN were evaluated intraoperatively by bisecting the lymph node and making imprints of each cut surface. Imprints were stained with hematoxylin and eosin (H&E) and Diff-Quik. Permanent sections were evaluated with up to four H&E stained levels and cytokeratin immunohistochemistry. Imprint cytology results were compared with final histologic results.

RESULTS

Sensitivity and specificity of imprint cytology were 56% and 100%, respectively, producing a 100% positive predictive value and 88% negative predictive value. Imprint cytology was significantly more sensitive for macrometastasis than micrometastasis 87% versus 22% (P = 0.00007). Of 13 total false negatives, 11 were found to be due to sampling error and 2 due to errors in intraoperative interpretation. Both intraoperative interpretation errors involved a diagnosis of lobular breast carcinoma.

CONCLUSIONS

The sensitivity and specificity of imprint cytology are similar to that of frozen section evaluation. Imprint cytology is therefore a viable alternative to frozen sectioning when intraoperative evaluation is required. If SLN micrometastasis is used to determine the need for further lymphadenectomy, more sensitive intraoperative methods will be needed to avoid a second operation.

Intraoperative touch imprint of sentinel lymph nodes in breast carcinoma patients

BACKGROUND

Sentinel lymph node examination in patients with breast carcinoma has been gaining in popularity. Currently, there is no standard intraoperative assessment of sentinel lymph nodes. To assess the utility of an intraoperative touch imprint (TI) evaluation, the authors compared TI cytology with surface hematoxylin and eosin (H&E) histology in sentinel lymph nodes from patients with breast carcinoma.

METHODS

Sixty five sentinel lymph node biopsy cases were identified. Diagnoses from TI and surface H&E histologic sections were compared.

RESULTS

Touch imprint had a specificity of 100%, a negative predictive value of 88%, a sensitivity of 65%, and a false negative rate of 9% per sentinel lymph node biopsy case. Eighty three percent of the false negative TI cases were due to micrometastasis. Preoperative chemotherapy, primary tumor type, and primary tumor size did not significantly contribute to false negative events. Touch imprint identified 67% of the cases that required completion axillary dissection.

CONCLUSIONS

Touch imprint is a reliable and accurate intraoperative technique, with the potential to save a significant number of patients morbidity and the cost of a second surgical procedure to remove axillary lymph nodes. The difficulty of identifying micrometastases appeared to be the major source of false negative events, a problem that is not unique to TI cytology.

Intraoperative evaluation of sentinel lymph nodes for breast carcinoma: current methodologies

Sentinel lymph node biopsy is an important new addition to the surgical management of patients with breast carcinoma. Sentinel nodes have a higher chance of containing metastases than do nonsentinel nodes. Sentinel lymph node biopsy provides an opportunity to stage breast carcinoma patients more accurately and to modify subsequent treatment. One of the most exciting current roles of sentinel lymph node biopsy is the ability to stage patients intraoperatively, allowing a one-step axillary lymph node dissection if the sentinel lymph node contains metastatic carcinoma. Currently, intraoperative evaluation of sentinel lymph nodes is performed using imprint cytology with or without rapid cytokeratin staining, frozen sectioning with or without rapid cytokeratin staining, scrape preparations, or some combination of these techniques. We review the relative strengths and weaknesses of these different methodologies. A great deal of controversy exists regarding the management of patients with metastatic breast carcinoma, particularly those patients with occult and micrometastatic disease. These issues are beyond the scope of this article.

Intraoperative evaluation of sentinel lymph nodes for metastatic melanoma by imprint cytology

BACKGROUND

Sentinel lymph node (SLN) biopsy has revolutionized lymph node staging in patients with malignant melanoma. Intraoperative evaluation is a new addition to the SLN procedure that allows for a one-step regional lymph node dissection to be performed when the SLN biopsy findings are positive. To date, several studies have evaluated the use of intraoperative frozen sectioning to evaluate the SLN in patients with melanoma. The literature pertaining to the use of intraoperative imprint cytology (IIC) to evaluate the SLN in melanoma patients is scant and to the authors' knowledge studies published to date are relatively small. The purpose of the current study was to evaluate the utility of IIC in patients undergoing SLN for melanoma.

METHODS

A total of 235 SLN biopsies from 93 patients with malignant melanoma and 3 patients with atypical Spitz nevi were examined by IIC after SLN biopsy using a double indicator technique. The SLNs were bisected and a pair of imprints were made from each half. One imprint from each half was stained with hematoxylin and eosin (H & E) whereas its counterpart was stained with Diff-Quik. Paraffin-embedded permanent sections were examined using multiple H & E stained sections from the SLNs in conjunction with immunohistochemical staining for S-100 and HMB-45 proteins.

RESULTS

A total of 235 SLNs were excised from 93 patients (2.5 SLNs per patient). On a per patient basis, metastases were identified in 21 patients (23%) on permanent section evaluation. Of these 21 patients, 8 were detected by IIC (sensitivity of 38%). The negative predictive value was 85%. No false-positive results were identified (specificity of 100%). The positive predictive value was 100%. The overall accuracy of the intraoperative evaluation was 86%. Patients found to have positive SLNs by IIC went on to undergo lymphadenectomy under the same anesthetic.

CONCLUSIONS

The sensitivity and specificity of IIC are similar to those of intraoperative frozen-section evaluation. Therefore, IIC appears to be a viable alternative to frozen sectioning when intraoperative evaluation is required. IIC evaluation of SLN makes a single surgical procedure possible for patients with malignant melanoma who are undergoing SLN.

Recommendations for sentinel lymph node processing in breast cancer

The status of the sentinel lymph node (SLN) has been shown to accurately reflect the presence or absence of metastases in the axilla in patients with breast cancer. This study was designed to determine the optimal protocol for SLN processing. A total of 173 SLNs from 96 breast cancer patients who had successful SLN localization and underwent completion axillary node dissection were identified. All SLNs were negative for metastases by initial routine histologic evaluation. The nodes were submitted in a total of 300 blocks. Each block was serially sectioned to produce 10 levels. Pan-cytokeratin stain was performed on levels 3 and 8. All other levels were stained with hematoxylin and eosin. Metastases were identified in 22 SLNs from 19 patients by examining all 10 levels. The first two hematoxylin and eosin- or the first cytokeratin-stained levels were positive for metastases in 21 (95.5%) of the 22 positive SLNs. Two additional hematoxylin and eosin-stained and one cytokeratin-stained levels of each SLN correctly identified the status of the node in 94 (97.9%) of 96 patients. Therefore, we recommend that after an initial hematoxylin and eosin-stained section, two additional hematoxylin and eosin-stained sections and one cytokeratin-stained section should be evaluated.

Sentinel lymph node biopsy and breast cancer

BACKGROUND AND METHOD

This paper reviews and discusses the feasibility and accuracy of sentinel lymph node (SLN) biopsy in breast cancer. A standardized method of identifying the SLN and detecting micrometastases is suggested, along with a strategy for the elimination of routine axillary lymph node dissection (ALND).

RESULTS

Although the SLN can be identified successfully by experienced practitioners using either the dye-guided or gamma probe-guided method, identification is facilitated when the two techniques are combined. To improve the likelihood of spotting metastases in the SLN, it is desirable to perform step sectioning combined with haematoxylin and eosin staining and immunohistochemistry of permanent and frozen sections. SLN biopsy is as accurate for T2 tumours as it is for T1 tumours. However, it is highly unlikely that all false-negative cases can be eliminated, even by detailed histological examination. Nevertheless, patients with T1 tumours with micrometastases in the SLN have shown no evidence of tumour in the non-sentinel nodes. In other words, ALND can be avoided in these patients, even if histological examination of the SLN fails to detect micrometastasis.

CONCLUSION

In practice, routine ALND can be avoided in patients with T1 tumours when the identified SLN proves to be histologically negative. However, investigation of long-term regional controls and of survival in a prospective randomized trial is necessary before SLN biopsy can replace routine ALND, particularly for patients with T2 tumours.