Axillary sentinel lymph node examination in breast carcinoma.

OBJECTIVE: To evaluate whether the type of pathologic examination of breast sentinel nodes (frozen section, step sections, and immunoperoxidase staining) results in different percentages of nodes positive for metastatic disease. DESIGN: Twenty-eight consecutive patients with breast sentinel node biopsies were evaluated by step-sectioning the sentinel node(s) along with performing immunoperoxidase stains for low-molecular-weight cytokeratin and epithelial membrane antigen. SETTING AND PARTICIPANTS: The patients were from a university hospital and large private hospital. MAIN OUTCOME MEASURES: The results of the step sections and immunoperoxidase stains were compared with routine examination, that is, intraoperative frozen section along with a single hematoxylin-eosin slide. RESULTS: Nine cases were positive by routine evaluation, 10 by step sections, and 11 by immunoperoxidase staining. CONCLUSIONS: The large, multi-institutional studies of sentinel node utility must take into account the surgical pathology methods used to evaluate these specimens so that uniform techniques, which reliably predict the status of the axillary nodes, can be instituted at all institutions that use this procedure.     

Intraoperative evaluation of sentinel lymph nodes for metastatic breast carcinoma by imprint cytology.

BACKGROUND: The increasing utilization of lymphatic mapping techniques for breast carcinoma has made intraoperative evaluation of sentinel lymph nodes attractive. Axillary lymph node dissection can be performed during the initial surgery if the sentinel lymph node is positive, potentially avoiding a second operative procedure. At present the optimal technique for rapid sentinel lymph node assessment has not been determined. Both frozen sectioning and intraoperative imprint cytology are used for rapid intraoperative sentinel lymph node evaluation at many institutions. The purpose of this study is to evaluate experience with imprint cytology for intraoperative evaluation of sentinel lymph nodes in patients with breast cancer. METHODS: A retrospective review of the intraoperative imprint cytology results of 678 sentinel lymph node mappings for breast carcinoma was performed. Sentinel nodes were evaluated intraoperatively by either bisecting or slicing the sentinel node into 4 mm sections. Imprints were made of each cut surface and stained with H&E and/or Diff-Quik. Permanent sections were evaluated with up to four H&E stained levels and cytokeratin immunohistochemistry. Intraoperative imprint cytology results were compared with final histologic results. Results: The sensitivity of imprint cytology was 53%, specificity was 98%, positive predictive value was 94%, negative predictive value was 82% and accuracy was 84%. The sensitivity for detecting macrometastases (more than 2mm) was significantly better than for detecting micrometastases (相似文献   

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 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.     

Predictive factors of lymph node metastasis and effectiveness of intraoperative examination of sentinel lymph node in breast carcinoma: A retrospective Belgian study

Recently, several trials demonstrated the safety of omitting axillary lymph node dissection in clinically N0 patients with positive sentinel nodes in select subgroups. However, this fact is still troublesome to clarify to surgeons and clinicians, as they used to perform intraoperative examination of the sentinel node and axillary dissection for many years. Hence, we decided to review our practice. This is to firstly highlight the predictive factors of node metastasis and secondly, to evaluate the effectiveness of intraoperative examination of the sentinel node.There were 406 total procedures. The rate of positive lymph nodes in the final diagnosis was 27%. Factors associated with metastasis were age, tumour size, TNM classification, tumour grade, vascular invasion, molecular classification and KI-67 index.The rate of reoperation was 6.2% in cases with final positive nodes, however, the complementary ALND was justified in only 2.7%. Forty-nine percent of SLN were examined during surgery (IOESLN), whereby the false negative rate was 11.8%. Sixty-three intraoperative examinations were necessary to prevent a second operation on a patient.We recommend changing the clinical management of the axilla, resulting in fewer ALNDs in selected cN0, SLN-positive patients. In keeping with recent large clinical trial (ACOSOG Z0011, AMAROS and OTOASOR) data, our results support that intraoperative exam in selected cN0, SLN-positive Belgian patients is no longer effective.     

Prediction of nonsentinel lymph node metastasis in sentinel node-positive breast carcinoma

The incidence of nonsentinel (NSN) lymph node metastases in patients with a tumor-positive sentinel (SN) lymph node varies greatly from 20% to 70% in the published literature. Current practice is that most patients with a positive SN (micro- and macrometastases) undergo a complete axillary dissection. However, it has been shown by other investigators that a large number of patients with a positive SN do not necessarily need a complete axillary dissection. In this analysis, we reviewed the pathology slides from 58 patients who had undergone SN and axillary node dissection. The tumor size, histologic parameters, receptor (estrogen and progesterone), and HER-2neu oncoprotein expression were noted. Student t test and Fisher exact test were used for statistical analysis. Of 58 patients, 19 (32.7%) had NSN metastases. Primary tumor size (P < .002), size of SN metastatic tumor (P < .03), and the presence of extracapsular tumor extension (P < .0001) were associated significantly with NSN metastases. We have shown in this study that it would be possible to predict the NSN status based on primary tumor size, size of SN metastatic tumor, and presence of SN extracapsular tumor extension.     

Axillary staging of breast cancer and the sentinel node

Pathological aspects of axillary nodal staging of breast cancer and in particular sentinel lymph node (SLN) biopsy are reviewed. SLN biopsy seems an almost ideal staging procedure because it has both high accuracy and a low false negative rate. It may also allow a cost effective use of more sensitive methods of metastasis detection. However, the biological relevance of metastases detected only by modern tools remains to be elucidated. This review focuses on standard axillary staging and the histopathological investigation of SLNs, with emphasis on the intraoperative setting. Future trends including ancillary studies, quality control issues, prediction of non-SLN involvement, and suggestions concerning the minimum requirements for the histology of axillary SLNs are also discussed.     

Predicting sentinel lymph node metastases in infiltrating breast carcinoma with vascular invasion

Sentinel lymph node and clinically negative axillary node status was compared with well-known clinicopathological characteristics such as tumor size, histologic and nuclear grade, lymphovascular invasion, steroid receptor, and HER-2 status in patients with breast cancer (pT1 and pT2). Positive sentinel lymph nodes were found in 29 of 100 patients: 19 with metastases detected by hematoxylin and eosin staining and 10 with micrometastases confirmed by immunohistochemistry with cytokeratin. Positive sentinel lymph nodes were present in larger carcinomas (P < 0.03), more frequently in tumors with negative PR status (P < 0.037) and evident lymphovascular invasion (P < 0.002). Lymphovascular invasion was also associated with breast cancer of higher histologic (P = 0.011) and nuclear grade (P = 0.039). Tumor size and the presence of lymphovascular invasion were found to be significant predictors of pathologically positive sentinel lymph node in T1 and T2.     

Intra-operative examination of the sentinel node in breast cancer

Intra-operative sentinel node analysis allows immediate progression to axillary clearance in patients with node positive breast cancer and reduces the need for re-operation. Despite this, intra-operative sentinel node analysis is infrequently performed in Ireland. We report our experience using this technique. Sentinel node biopsy was performed in 47 consecutive patients with symptomatic T1-T2 clinically node negative breast cancer. Sentinel nodes were examined intra-operatively by frozen section and imprint cytology and definitive histological assessment was performed on paraffin-embedded tissue. The sentinel node was identified in 46 (98%) patients. Twelve patients had axillary metastases. The sensitivity of intra-operative analysis in identifying nodal metastases was 92%. False negative rate was 8%, negative predictive value 97%, and specificity 100%. Intra-operative analysis of the sentinel node allowed re-operation to be avoided in 92% of patients with axillary node metastases. In our experience this technique can be readily introduced with reliable outcomes.     

Paracortical axillary sentinel lymph node ectopic breast tissue

Benign glandular inclusions in axillary lymph nodes are uncommon, and their presence in axillary sentinel lymph nodes is exceptionally rare. The possibility of over-staging due to misinterpretation of glandular inclusions as metastatic carcinoma is a concerning issue. We present a 54-year-old female with high grade ductal carcinoma in-situ undergoing simple mastectomy with sentinel lymph node biopsy. Permanent sections of the sentinel lymph node revealed scarce naked small glands without surrounding stroma scattered in the paracortex in the superficial level. Deeper levels showed glands spanning a much larger area (2 mm), with bland ducts and tubules separated by abundant stroma. The myoepithelial layer was visible and was immunohistochemically confirmed. A final diagnosis of benign ectopic breast tissue within an axillary sentinel lymph node was rendered. Previous studies described axillary sentinel lymph nodes with glandular inclusions separated by stroma or subcapsular in location. It has been suggested that paracortical location and absence of stroma are characteristics of metastasis. As demonstrated in our report, benign inclusions may be paracortical and lack surrounding stroma. We recommend that glandular inclusions should be a diagnostic consideration for cases in which paracortically located naked glands do not histologically resemble the corresponding primary tumor.     

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.     

乳腺癌前哨淋巴结活检的方法和临床意义

在乳腺癌根治术中，腋窝淋巴结清扫的主要目的是：切除可能的转移病灶，指导进一步的辅助治疗。但近年的生物医学研究证实，乳腺癌从发生起即是全身性的疾病，早期乳癌的手术范围大小对病人预后影响不大；Fendas对24740例病人的腋窝淋巴结研究也证实，腋淋巴结的总转移率不足50％，小于1cm的浸润性乳癌，淋巴结浸润率仅为3％～7％，原位导管癌淋巴结浸润率仅约0％～1％。因此，专业论著中强调的乳腺癌进     

Strategies for optimizing pathologic staging of sentinel lymph nodes in breast cancer patients

Due to the extensive pathologic evaluation of the sentinel lymph node (SLN), micrometastases are frequently observed. If micrometastases are clinically relevant, the histopathologic examination of SLNs should be sensitive enough to detect them. The probability of detecting micrometastases was calculated when examining the SLN according to the current Dutch pathology protocol and strategies evaluated to optimize the chance of detection. The dimensions of 20 consecutive axillary SLNs in patients with cT1-2N0 breast cancer were measured. In a mathematical model, the probability of detecting micrometastases in a SLN was calculated. Similarly, strategies to optimize the probability of detecting micrometastases were explored. When applying the pathology guidelines, the calculated probability to detect a micrometastasis was 18% for a 200-microm micrometastasis and 69% for a 2.0-mm metastasis in a median sized SLN. To detect the smallest micrometastasis in a median-sized SLN with a 95% probability, the interval between the sections must be decreased to 200 microm, and 20 levels from both halves must be examined. Given a prognostic significance of micrometastases, our current pathology guidelines are not sensitive enough. The number of sections should be increased, while the interval between cuts should be no more than 200 microm.     

乳腺癌前哨淋巴结活检术中不同染色淋巴结与肿瘤转移的关系

目的探讨乳腺癌前哨淋巴结活检术(SLNB)中不同染色情况的淋巴结与肿瘤转移的关系。方法选择我院2014年1月至2018年1月行前哨淋巴结活检的乳腺癌患者92例,以亚甲蓝为示踪剂,根据92例乳腺癌患者SLNB中淋巴结染色情况的不同分为无染色组、完全染色组和染色不均组,病理检测3组患者淋巴结的肿瘤转移情况并作比较。结果92例乳腺癌SLNB共取得淋巴结256枚,平均每例患者2.8枚,无染色组(80枚)肿瘤转移率为13.8%,完全染色组(112枚)肿瘤转移率为43.8%,染色不均组(64枚)肿瘤转移率为62.5%,3组间肿瘤转移率差异有统计学意义(P<0.05)。结论乳腺癌SLNB中染色不均的淋巴结最易出现肿瘤转移,其次为完全染色的淋巴结,染色淋巴结附近看到的未染色淋巴结也有肿瘤转移的可能,宜一并切除送检,有利于降低假阴性率。     

前哨淋巴结活检术在早期宫颈癌中的应用价值

目的探讨前哨淋巴结（SLN）活检术在早期宫颈癌中的应用价值。方法选取2006年1月至2011年4月在我院及特定医院就诊早期子宫颈癌拟接受腹式盆腔淋巴结清扫和广泛子宫切除术患者42例,术中确定SLN,并将切除的SLN行快速冰冻病理检查。且不管术中SLN快速病理检查结果如何,对所有患者均实行前哨淋巴结活检术（SLNB）和盆腔淋巴结清扫术,对于病理检查SLN淋巴结阴性的患者术后不需要补充放疗,阳性的患者术后需补充放疗。术后对比SLNB的SLN阳性和阴性率与盆腔淋巴结清扫结果的淋巴结阳性和阴性率是否符合,是否具有阳性和阴性预测效率。并对所有患者术后按SLN阴性和SLN阳性进行3～5年的跟踪随访。结果SLN的阳性和阴性率与盆腔淋巴结清扫结果的淋巴结阴性和阳性率基本符合,具有较高的阳性和阴性预测效率。对所有患者术后结局按SLN阴性和SLN阳性常规3~5年跟踪随访,结果显示两组在专科检查、盆腔B超、残端HPV检测、复发时间及部位、复发率、5年存活率6个方面比较,差异均无统计学意义（P〉0．05）。结论以SLNB代替传统的宫颈癌盆腔淋巴结清扫术技术在临床具有较高的可行性和准确性,为宫颈癌临床缩小手术范围并减小手术并发症开创了一个全新的思路。     

Accuracy of axillary staging using sentinel node biopsy or diagnostic axillary lymph node dissection--a case-control study

We aimed to compare the accuracy of axillary staging in breast cancer between sentinel node biopsy (SNB) and axillary lymph node dissection (ALND). The prevalence of axillary metastases was studied in 166 breast cancer patients with SNB and pair-matched control patients with ALND. The matching factors included age of the patient and grade, histological type and histological size of the tumour. There were 37% of patients with axillary metastases in the SNB group and 31% in the ALND group. Altogether, 57 pairs were discordant in relation to axillary metastases. In 34 discordant pairs the SNB patient and in 23 the ALND patient had axillary metastases, p=ns. Among the 36 discordant pairs with invasive ductal carcinoma (IDC), axillary metastases were detected as often in the SNB and the ALND patients. In the 21 discordant pairs with other histological types, the SNB patient had axillary metastases in 16 pairs and the ALND patient in 5 pairs, p<0.03. SNB seems to be as accurate a method for axillary staging as ALND. However, SNB generated no upstaging effect in IDC, only in other histological tumour types.