The Utility of Intraoperative Evaluation of Sentinel Lymph Nodes in Breast Cancer

Diagnostic value of intraoperative histopathological examination of the sentinel nodes in breast cancer and skin melanoma-Preliminary results of single centre retrospective study

OBJECTIVE

Intraoperative histopatological examination of the sentinel nodes enables selection of patients who need dissection of the regional lymphatic system during the same operation. The aim of this study is to evaluate the diagnostic value of intraoperative histopathological examination of the sentinel nodes in breast cancer and skin melanoma. Intraoperative histopathology of the sentinel nodes as a diagnostic method is used in patients with melanoma and breast cancer. Recent studies have proved it to be an effective method for evaluating the nodes in the final histopathology. Intraoperative histopathological examination of the sentinel nodes is not performed routinely and there is no clear position on this issue. In this paper we try to prove that intraoperative test gives patients the simultaneous benefits of removal of regional lymph nodes metastases and earlier initiation of adjuvant therapy.

METHODS

The study comprises 137 patients with breast cancer and 35 patients with malignant skin melanoma. Sentinel nodes were intraoperatively sectioned and examined by means of the imprint method and frozen section evaluation. The patients with positive sentinel nodes underwent immediate dissection of regional lymph nodes. Those with negative sentinel nodes diagnosed in the intraoperative examination, but positive in final pathologic results, underwent subsequent dissection of regional lymph nodes.

RESULTS

60 sentinel lymph nodes were found in 35 patients with skin melanoma. In 3 patients, 3 sentinel lymph nodes were false negative in the intraoperative histopathological examination. No false positive sentinel lymph nodes were found. 249 sentinel lymph nodes were found in the intraoperative histopathological examination in 137 patients with breast cancer. There were no false positive sentinel nodes, but there were 7 false negative sentinel nodes. In this study, only 5 (3.6%) patients with breast cancer and 3 (8.5%) patients with skin melanoma required another regional operation.

CONCLUSION

The method of intraoperative histopathological evaluation of the sentinel nodes enables identification of metastases in these lymph nodes and gives a possibility to carry out a one-step regional lymphadenectomy and start the adjuvant therapy earlier.

Multicentre evaluation of intraoperative molecular analysis of sentinel lymph nodes in breast carcinoma

Background

Ideally, intraoperative sentinel lymph node (SLN) analysis in breast cancer should be automated, have high concordance with extensive histopathology, and be applicable in any hospital setting. A prospective multicentre evaluation of the one-step nucleic acid amplification (OSNA) automated molecular diagnostic system of SLN analysis was undertaken.

Methods

Intraoperative examination of SLNs from 204 patients with breast cancer was performed by OSNA at four sites in the UK. Half of each SLN was assessed by OSNA (for cytokeratin 19 mRNA) and the remaining half was paraffin embedded for intensive histological examination at ten levels. Discordant cases were reanalysed by further molecular biological techniques and by additional histological examination of all remaining nodal material to ascertain whether the discordance was due to an uneven distribution of metastases, known as tissue allocation bias (TAB).

Results

After exclusion of samples affected by TAB, the overall concordance rate for OSNA versus histopathology was 96·0 per cent, with a sensitivity of 91·7 per cent and a specificity of 96·9 per cent. The median time to process a single SLN was 32 (range 22–97) min, and that for two nodes 42 (30–73) min.

Conclusion

OSNA enables accurate automated intraoperative diagnosis and can be used successfully in different UK hospitals. When the SLN is shown to be positive, the patient can undergo immediate axillary clearance under the same anaesthetic rather than having a delayed second procedure.

Impact of Sentinel Lymph Node Biopsy on Immediate Breast Reconstruction after Mastectomy

Traditionally, sentinel lymph node biopsy (SLNB) is performed at the time of mastectomy and reconstruction. However, several groups have advocated SLNB as a separate outpatient procedure before mastectomy, when immediate reconstruction is planned, to allow for complete pathologic evaluation. The purpose of this study was to determine the impact of intraoperative analysis of SLNB on the reconstructive plan when performed at the same time as definitive surgery. A retrospective review was conducted of all mastectomy cases performed at a single institution between September 1998 and November 2007. Of the 747 mastectomy cases reviewed, SLNB was conducted in 344 cases, and there was immediate breast reconstruction in 193 of those cases. There were 27 (7.8%) false negative and three (0.9%) false positive intraoperative analysis of SLNB. Touch preparation analysis from the SLNB changed the reconstructive plan in four (2.1%) cases. In our experience, SLNB can be performed at the time of mastectomy with minimal impact on the reconstructive plan. A staged approach incurs significant additional expense, increases the delay in initiation of systemic therapy and the propensity of procedure-related morbidity; therefore, SLNB should not be performed as a separate procedure before definitive surgery with immediate breast reconstruction.

Identification and biologic significance of micrometastases in axillary lymph nodes in patients with invasive breast cancer

CONTEXT

The presence or absence of metastases in axillary lymph nodes is one of the most important prognostic factors for patients with breast cancer. During the past decade sentinel lymph node (SLN) biopsy has been increasingly adopted as a minimally invasive staging alternative to complete axillary node dissection.

OBJECTIVE

Sentinel lymph nodes are more likely to contain metastases than non-SLNs. In routine clinical practice SLNs are assessed by diverse methodologies including multiple sectioning, immunohistochemical staining, and molecular diagnostic tests. Despite the lack of standard histopathologic protocols during the years detailed evaluation of SLNs has resulted in an increased detection of small (micro) metastases.

DATA SOURCES

Breast cancer with micrometastases constitutes a heterogenous group of tumors with variable clinical outcome regarding the risk of additional metastases in the remaining axillary lymph nodes and to patients' survival.

CONCLUSION

The clinical significance of micrometastases has been subject to great controversy in patients with breast cancer. In this review we highlight controversies regarding micrometastases especially in relation to SLNs.

A prospective study comparing touch imprint cytology, frozen section analysis, and rapid cytokeratin immunostain for intraoperative evaluation of axillary sentinel lymph nodes in breast cancer

BACKGROUND

The intraoperative evaluation of axillary sentinel lymph nodes (SLNs) allows the surgeon to complete axillary dissection in 1 setting at the time of the primary breast surgery. However, to the authors' knowledge, there is no consensus regarding the optimal method for intraoperative evaluation of SLNs in breast cancer. The authors of this report prospectively compared touch imprint (TI) cytology with frozen section (FS) analysis and rapid cytokeratin immunostaining (RCI) of SLNs for the intraoperative evaluation of disease and compared the results with final pathologic examination (FP).

METHODS

Patients with invasive breast carcinoma who were diagnosed with lymph node-negative disease (based on preoperative clinical and sonographic evaluation with or without fine-needle aspiration of the indeterminate lymph nodes) and who subsequently were scheduled for lymphatic mapping were eligible to participate in this prospective protocol. TI and FS analysis were performed on all SLNs, and the lymph nodes were stained by the hematoxylin and eosin (H&E) method. RCI was performed using the enhanced polymer 1-step cytokeratin method. The results of TI, FS, RCI, TI plus FS, and FS plus RCI were compared with the results from FP, including 1 H&E stain and cytokeratin immunostain of the third level.

RESULTS

One hundred patients with invasive mammary carcinoma were accrued to the study. Eighty-five tumors were the ductal type, 8 tumors were lobular, 5 tumors were mixed ductal and lobular, 1 was an adenoid cystic tumor, and 1 tumor was metaplastic carcinoma. Seventy-two tumors were staged clinically as T1N0M0, 25 tumors were staged as T2N0M0, and 3 tumors were staged as T3N0M0. Metastatic carcinoma was detected in the SLNs by 1 or more methods, including TI, FS, RCI, and FP, in 20 tumors, which included 12 macrometastases and 8 micrometastases. TI detected 8 of 12 macrometastases (67%), FS detected 12 of 12 macrometastases (100%), RCI detected 12 of 12 macrometastases (100%), and FP detected 12 of 12 macrometastases (100%). TI detected 1 of 8 micrometastases (13%), FS detected 3 of 8 micrometastases (38%), RCI detected 4 of 8 micrometastases (50%), and FP detected 6 of 8 micrometastases (75%). The sensitivities of TI, FS, RCI, TI plus FS, and FS plus RCI (with FP as the gold standard) were 50%, 72%, 78%, and 83%, respectively, and the sensitivities of the same intraoperative methods were 45%, 75%, 80%, and 85%, respectively, with detection of metastatic disease by any method as the gold standard. The specificities of the different methods (with FP as the gold standard) were 100% for TI and 97.5% for FS, RCI, TI plus FS, and FS plus RCI. The specificity of each method was 100% when the detection of metastatic disease by any method was regarded as the gold standard. Although the difference in sensitivity between FS and TI was not statistically significant (P = .08), the difference between RCI and TI bordered on significance (P = .046); however, FS analysis plus RCI was significantly superior to TI (P = .03) and produced results comparable to those of FP.

CONCLUSIONS

The sensitivities of FS, RCI, TI plus FS, and FS plus RCI were better than the sensitivity of TI cytology of axillary SLNs. However, only the combination of FS and RCI was statistically superior to TI and generated results comparable to those of FP in SLNs. RCI can be completed within the time constraints for intraoperative use and, in conjunction with FS, can be useful for generating results closer to those generated by FP. FS analysis plus RCI have a role in the intraoperative evaluation of SLNs.

Intraoperative consultation for axillary sentinel lymph node biopsy: an 8-year audit

To summarize the authors' 8-year institutional experience with intraoperative consultation via frozen section (FS) on sentinel lymph node biopsy (SLNB) in breast cancer patients we recorded the, complete operative procedure including additional surgery on the ipsilateral axilla and intraoperative consultation and permanent histopathologic processing for all cases with inoperative consultation on SLNB in breast cancer patients between the groups, chi(2) and Fisher's exact tests were used. Intraoperative consultation was positive in 116/706 cases (16.4%) and final pathology in 158/706 cases (22.4%); the false-negative rate was 26.6%, the false-positive rate was 0%, and the overall accuracy was 94%. False-negative rate was significantly associated with the size of metastasis (micro vs macrometastasis; P < .002) but not significantly associated with the histologic type (P = 0.76) or pathologist expertise (P = 0.08). The rate of spared second procedures was 92% when calculated exclusively for patients who ultimately underwent ALND. Intraoperative consultation via FS for SLNB is a safe practice that can reliably save clinically node-negative patients a second surgery.

Management of the axilla after the finding of a positive sentinel lymph node: a proposal for an evidence-based risk-adapted algorithm

Axillary lymph node dissection after the finding of a positive sentinel lymph node is a common clinical practice. A review is performed for the efficacy and morbidity of axillary lymph node dissection, the rationale for nonsurgical management of the axilla, and the efficacy, technical limitations, and toxicity of axillary radiation therapy; a management algorithm is then proposed based upon currently available prediction tools.

A prospective, blinded trial of touch prep analysis versus frozen section for intraoperative evaluation of sentinel lymph nodes in breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) has largely replaced axillary dissection (ALND) for axillary staging in early breast cancer. However, intense pathologic evaluation is not routinely available intraoperatively; therefore, patients with SLN metastasis may require a second surgery for completion ALND. We hypothesized that a single-section approach (by either frozen section [FS] or touch preparation analysis [TPA]) could be accurate for intraoperative SLN evaluation.

METHODS

We performed a prospective, blinded study of patients undergoing SLNB for breast cancer from September 2004 to July 2006. SLNs were bivalved along the long axis, underwent FS and TPA of the facing halves, followed by routine sentinel node processing (serial sectioning with hematoxylin/eosin staining). A single pathologist reviewed all study slides and was blinded to the permanent section interpretation.

RESULTS

We analyzed 233 nodes from 118 patients. Overall, 21% of patients (N = 25) had SLN metastasis by serial-section histopathology. Single-section FS and TPA had similar sensitivities (0.67 and 0.66, P = .82) and specificities (0.995 and 0.995, P = 1.0) for detection of SLN metastasis, yielding equivalent accuracies (95%). All micrometastases (<2 mm; N = 4) were missed by both techniques. False positives were rare-only one in each group (2% overall).

CONCLUSION

Single-section TPA and FS have similar accuracies and can be safely used to identify the majority of patients with SLN metastasis, sparing these patients a delayed ALND. False-negative results from TPA or FS occur in patients with micrometastatic disease, for which the role of completion ALND remains controversial.

Imprint cytology on microcalcifications excised by vacuum-assisted breast biopsy: a rapid preliminary diagnosis

BACKGROUND

To evaluate imprint cytology in the context of specimens with microcalcifications derived from Vacuum-Assisted Breast Biopsy (VABB).

PATIENTS AND METHODS

A total of 93 women with microcalcifications BI-RADS 3 and 4 underwent VABB and imprint samples were examined. VABB was performed on Fischer's table using 11-gauge Mammotome vacuum probes. A mammogram of the cores after the procedure confirmed the excision of microcalcifications. For the application of imprint cytology, the cores with microcalcifications confirmed by mammogram were gently rolled against glass microscope slides and thus imprint smears were made. For rapid preliminary diagnosis Diff-Quick stain, modified Papanicolaou stain and May Grunwald Giemsa were used. Afterwards, the core was dipped into a CytoRich Red Collection fluid for a few seconds in order to obtain samples with the use of the specimen wash. After the completion of cytological procedures, the core was prepared for routine histological study. The pathologist was blind to the preliminary cytological results. The cytological and pathological diagnoses were comparatively evaluated.

RESULTS

According to the pathological examination, 73 lesions were benign, 15 lesions were carcinomas (12 ductal carcinomas in situ, 3 invasive ductal carcinomas), and 5 lesions were precursor: 3 cases of atypical ductal hyperplasia (ADH) and 2 cases of lobular neoplasia (LN). The observed sensitivity and specificity of the cytological imprints for cancer were 100% (one-sided, 97.5% CI: 78.2%-100%). Only one case of ADH could be detected by imprint cytology. Neither of the two LN cases was detected by the imprints. The imprints were uninformative in 11 out of 93 cases (11.8%). There was no uninformative case among women with malignancy.

CONCLUSION

Imprint cytology provides a rapid, accurate preliminary diagnosis in a few minutes. This method might contribute to the diagnosis of early breast cancer and possibly attenuates patients' anxiety.