One hundred consecutive cases of sentinel lymph node mapping in early colorectal carcinoma: Detection of missed micrometastases

Almost one third of patients with "node-negative" colorectal carcinoma (CRC) develop systemic disease. This implies that these patients have occult disease that is inadequately treated by surgery alone. We have coupled sentinel lymph node mapping and a focused pathologic examination to detect occult nodal micrometastases in CRC. Since 1996, sentinel lymph node mapping has been performed in 100 consecutive patients undergoing colectomy for CRC. Peritumoral injection of 0.5 to 1.0 ml of isosulfan blue dye was performed to demonstrate the sentinel node(s). All lymph nodes in the resection specimen were examined by routine hematoxylin and eosin staining. In addition, a focused examination of multiple sections of the sentinel nodes was performed using both hematoxylin and eosin and cytokeratin immunohistochemical analysis (CK-IHC). Overall, lymphatic mapping successfully demonstrated one to four sentinel lymph nodes in 97 (97%) of 100 patients. These sentinel nodes accurately reflected the status of the nodal basin in 92 (95%) of 97 patients. All five of the false negative cases occurred in T3/T4 tumors, and three of the five occurred during the first 30 cases in the experience. Unexpected lymphatic drainage was encountered in eight patients (8%) and altered the operative approach. Twenty-six patients were node positive by routine hematoxylin and eosin staining. Of the remaining 74 patients with hematoxylin and eosin-negative nodes, an additional 18 patients (24%) were upstaged by identification of occult nodal micrometastases that were missed on routine hematoxylin and eosin staining but detected on multiple sections (n = 5) or by CK-IHC (n = 13). The sentinel lymph nodes were the only positive nodes in 19 cases. Sentinel lymph node mapping may be performed in CRC with a high degree of success and accuracy. A focused pathologic examination of the sentinel node detects micrometastatic disease that is missed by conventional techniques in a significant proportion of patients with early CRC. Further studies are necessary to elucidate the clinical relevance of these micrometastases. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation). Supported in part by grant T32 CA 09689 and 090848 from the National Cancer Institute and by funding from the Rogovin-Davidow Foundation, Los Angeles, California and the Rod Fasone Memorial Cancer Fund, Indianapolis, Indiana.     

Validation of Lymphatic Mapping in Colorectal Cancer: In Vivo, Ex Vivo, and Laparoscopic Techniques

Background:The use of lymphatic mapping (LM) is being investigated to improve the staging of colorectal cancer (CRC) and thereby identify patients who might benefit from adjuvant chemotherapy. This study evaluated in vivo, laparoscopic, and ex vivo approaches for the ultrastaging of CRC.Methods:Seventy-five CRC patients were enrolled in a study of LM with peritumoral injection of isosulfan blue dye. LM was undertaken during open colon resection (OCR) in 64 patients, during laparoscopic colon resection (LCR) in 9 patients, and after specimen removal (ex vivo) in 2 patients. Ex vivo LM was also undertaken in 6 patients after unsuccessful in vivo LM. All nodes were examined by hematoxylin and eosin (H&E) staining; in addition, sentinel lymph nodes (SNs) were multisectioned and examined by immunohistochemical staining with cytokeratin (CK-IHC).Results:At least one SN was identified in 72 patients (96%). In vivo LM identified SNs in 56 of 64 (88%) patients undergoing OCR and in 9 of 9 (100%) patients undergoing LCR. Ex vivo LM was undertaken as the initial mapping procedure in 2 cases of intraperitoneal colon cancer and after in vivo LM had failed in 6 cases of extraperitoneal rectal carcinoma; an SN was identified in 7 of the 8 cases. Focused examination of the SN correctly predicted nodal status in 53 of 56 OCR cases, 9 of 9 LCR cases, and 6 of 7 ex vivo cases. Multiple sections and CK-IHC identified occult micrometastases in 13 patients (17%), representing 10 OCR, 1 LCR, and 2 ex vivo cases.Conclusions:LM of drainage from a primary CRC can be accurately performed in vivo during OCR or LCR. Ex vivo LM can be applied when in vivo techniques are unsuccessful and may be useful for rectal tumors. During LCR, colonoscopic injection can be used to mark the primary tumor and define the lymphatic drainage so that adequate resection margins are obtained. These LM techniques improve staging accuracy in CRC.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16-19, 2000     

Lymphatic mapping improves staging during laparoscopic colectomy for cancer

Background: Recently, lymphatic mapping (LM) of the sentinel lymph node (SN) has been coupled with ultrastaging methods to diagnose nodal micrometastases from colorectal cancer (CRC). We have developed a technique for LM at the time of laparoscopic colon resection (LCR). Methods: Between August 1996 and February 2000, 11 patients with small early-stage CRC underwent laparoscopic LM and LCR. The primary tumor/polyp site was visualized through a colonoscope and either tattooed preoperatively with a carbon dye (India ink), or stained intraoperatively by peritumoral injection of isosulfan blue dye. Immediately after intraoperative injection of blue dye, efferent lymphatic channels were visualized through the laparoscope and followed to the SN. Each blue-stained SN was marked with a suture or clip. Results: In all 11 cases, laparoscopic LM identified between one and three SN draining the primary tumor. LM added ~15-20 min to the operating time. The SN correctly reflected the nodal status of the entire specimen in all cases. In the one node-positive case, micrometastases were found only in an SN and only after cytokeratin immunohistochemistry (CK-IHC). In four cases, LM demonstrated unexpected primary lymphatic drainage that prompted an increase in the margins of resection. Conclusions: LM during laparoscopic colectomy for CRC may be useful to mark the primary tumor site and to demonstrate lymphatic drainage that can alter the margins of resection. Focused examination of SN identifies occult micrometastases that up-stage CRC. apd: 2 May 2001     

结直肠癌前哨淋巴结体外标本定位及其微转移免疫组化研究

目的探讨结直肠癌前哨淋巴结（SLN）体外定位技术方法及其可行性、准确性和临床价值。方法选择2003年3月至2003年10月间中山大学肿瘤防治中心腹科住院行根治手术的结直肠癌患者60例,62个肿瘤（2例患者为多原发）,进行体外SLN定位。标本离体后尽早进行异硫蓝SLN定位,传统病理检查阴性的SLN进行细胞角蛋白免疫组化检查。结果62例肿瘤成功检出SLN的59例,检出率95．2％。59例患者总共获得并检测1114枚淋巴结,平均每人18．9（4～46）枚。其中SLN157枚（14．9％）,平均每人2．7（1～9）枚。SLN敏感性39．1％（9／23）,假阴性率23．7％（14／59）,准确率76．3％（45／59）。50例SLN阴性的中有12例（24％）细胞角蛋白免疫组化检测阳性。36例HE和细胞角蛋白免疫组化检查全阴性者中4例（11．1％）SLN发现微转移灶。14例仅非SLN阳性中8例SLN发现微转移灶。结论结直肠癌异硫蓝SLN体外定位活检技术是可行的,结合免疫组化检测微转移可以提高术后分期,可以提高送检淋巴结个数,结合免疫组化技术,可以减少淋巴结转移漏诊发生率。但该方法假阴性率较高,不能完全取代常规淋巴结病理检查。     

Focused examination of sentinel lymph nodes upstages early colorectal carcinoma

Approximately 30 per cent of patients with early colorectal carcinoma (CRC) develop systemic disease. A subgroup of these patients may harbor occult micrometastatic disease and might benefit from adjuvant chemotherapy. We investigated sentinel lymph node (SLN) mapping and focused pathologic examination of the SLN as a means of detecting nodal micrometastases. Between 1996 and 2000 SLN mapping was performed in 50 consecutive patients undergoing colectomy for CRC. All lymph nodes in the resection specimen were examined via routine hematoxylin and eosin (H&E) staining. In addition multiple sections of each SLN were examined via both H&E and cytokeratin immunohistochemistry. At least one SLN was identified in 47 patients (94%). In seven patients (14%) SLN mapping identified aberrant drainage that altered the planned resection. The SLN(s) correctly predicted nodal basin status in 44 of 47 (94%) cases; there were three falsely negative SLNs. Sixteen cases had positive SLNs by conventional H&E staining. An additional 10 (20%) cases were upstaged by a focused examination of the SLNs. Micrometastases were identified in three cases by H&E staining of multiple sections of the SLN and in seven only by cytokeratin immunohistochemistry. In nine cases the SLN was the only node containing tumor cells. In this study, SLN mapping demonstrated aberrant nodal drainage patterns that altered the surgical resection in patients with CRC. Focused examination of SLNs may detect micrometastases missed by conventional techniques and thereby identify patients who might benefit from adjuvant therapy.     

非小细胞肺癌淋巴结微转移的临床病理研究

目的 探讨免疫组化染色检测非小细胞肺癌淋巴结微转移的可行性。方法 将25例肺癌患者术中获取的淋巴结标本进行石蜡包埋,然后连续切片,6～10张不等,切片厚为5μm。选择第1和倒数第2张切片进行苏木精伊红染色,剩余切片用于免疫组化染色。免疫组化所选抗体为鼠抗人细胞角蛋白19单克隆抗体。结果 195枚淋巴结接受了苏木精伊红染色检查。9例患者共30枚淋巴结中发现有显性转移,无一例患者的淋巴结中检测出微转移。135枚苏木精伊红染色阴性的淋巴结又进行了免疫组化染色检查,有31枚淋巴结病理切片中显现出了癌微转移。16例常规病理PN0期患者中,5例患者肺门淋巴结出现了微转移;另9例常规病理PN1期患者中,4例出现了纵隔淋巴结的微转移,差异有统计学意义（x^2=52．900,P=0．0193）。结论 普通苏木精伊红染色能准确地检测出非小细胞肺癌淋巴结中的显性转移灶,而不易发现隐匿性微转移灶。免疫组化染色能提高非小细胞肺癌淋巴结微转移的检出率,并可对部分Ⅰ、Ⅱ期患者重新进行TNN分期。     

Combination probe and dye-directed lymphatic mapping detects micrometastases in early colorectal cancer

Nodal metastasis is the single most important prognostic factor in early colorectal cancer (CRC). Lymphatic mapping can identify sentinel nodes for focused histopathologic examination and thereby improve the nodal staging of CRC; however, the optimal technique for identifying sentinel nodes in CRC is unclear. We hypothesized that a combination of radiotracer and blue dye would more accurately identify tumor-positive sentinel nodes than blue dye alone. Lymphatic mapping was performed in 48 consecutive patients undergoing resection for CRC and in two original patients who underwent sentinel node mapping in 1996. Prior to resection, 1% vital blue dye and radiotracer were injected around the tumor in the subserosal layer. Nodes were designated as sentinel by blue coloration and/or radioactivity. Lymphatic mapping identified at least one sentinel node in 49 patients. Focused examination of multiple sentinel node sections by means of hematoxylin and eosin and immunohistochemical analysis showed that sentinel nodes accurately predicted the status of the nodal basin in 93.8% (46 of 49) of patients. Of the 19 patients with nodal metastases, 11 had macrometastases (>.2 mm), three had micrometastases (between 2 mm and 0.2 mm), and five had isolated tumor cells or clusters (<.2 mm) identified by immunohistochemical analysis only.Patients had significantly fewer blue/radioactive (“hot”) nodes than blue-only nodes (1.38 vs. 2.48 per patient; P = 0.0001). It is important to note that nodal metastases were more common in blue/ hot nodes than in blue-only nodes (27.3% [19 of 68] vs. 8.8% [11 of 124]; P = 0.005). Dual-agent lymphatic mapping more accurately identifies sentinel node metastases than blue dye alone. In addition, this technique allows a more focused histopathologic examination of these nodes, in conjunction with the revised American Joint Committee on Cancer guidelines, and thereby offers the potential for significant upstaging of CRC. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation). Supported by grant CA090848 from the National Cancer Institute; the Rogovin-Davidow Foundation, Los Angeles, California; the Rod Fasone Memorial Cancer Fund, Indianapolis, Indiana; and U.S. Surgical Corp., Norwalk, Connecticut.     

淋巴绘图和前哨淋巴结定位在腹腔镜结肠癌切除术中的应用

目的 探讨淋巴绘图(LM)和前哨淋巴结(SLN)定位分析在腹腔镜结肠癌手术中的应用价值.方法 32例结肠癌患者,术中在纤维电子肠镜辅助下,将0.5～1.0 mL异硫蓝染剂注射在瘤体四周的黏膜下层,随即通过腹腔镜观察,蓝染的SLN清晰可见.结肠采用标准术式切除.所有淋巴结经苏木精-伊红(HE)染色,对每一个SLN进行多点取材,同时进行HE染色及抗细胞角蛋白免疫组织化学(IHC)染色双重病理检查.结果 所有患者在腹腔镜下至少识别1个SLN.94%成功检出SLN,并正确反映了该区域淋巴结的肿瘤状况.8例(25.0%)蓝染的淋巴管系超出了术前预计范围,术中实行了宽系膜切除.4例(12.5%)患者的SLN经HE染色阴性而IHC染色证实存在微转移灶.结论 SLN绘图在腹腔镜结肠癌切除术中,可以指导切除范围;联合应用IHC染色可以提高肿瘤分期,将对患者手术方式的选择和预后评估更加准确.     

A caution regarding lymphatic mapping in patients with colon cancer

BACKGROUND: The value of lymphatic mapping and sentinel lymph node biopsy in the treatment of colon cancer is controversial. The purpose of this study was to determine the accuracy of lymphatic mapping in patients with colon cancer. METHODS: Forty-eight patients with colon cancer underwent lymphatic mapping and sentinel lymph node biopsy using isosulfan blue dye followed by standard surgical resection. The sentinel lymph nodes underwent thin sectioning as will as immunohistochemical staining for cytokeratin, in addition to standard hematoxylin and eosin staining. RESULTS: In 47 (98%) patients, a sentinel lymph node was identified. Sixteen patients had lymph nodes containing metastatic disease, and in 6 patients the sentinel lymph node was positive for disease. In no patient was the sentinel lymph node the only site of metastatic disease. In 10 patients the sentinel lymph node was negative for disease, whereas the nonsentinel lymph nodes contained metastatic disease (false negative rate = 38%). CONCLUSIONS: The role of lymphatic mapping and sentinel lymph node biopsy in colon cancer is not as clear as its role in other tumors. Further large prospective studies are needed to evaluate the accuracy and potential benefit of this procedure in patients with colon cancer.     

Sentinel lymph node dissection for primary cutaneous melanoma: a community hospital's initial experience

Management of the regional lymph nodes remains the most controversial aspect of treating patients with intermediate-thickness cutaneous melanoma. Prospective studies have failed to demonstrate a significant survival advantage for patients undergoing elective lymph node dissection. The sentinel lymph node dissection (SLND) technique has been proposed as a method of accurately identifying patients with occult metastases in whom a regional lymph node dissection would be indicated. The majority of studies evaluating this technique have come from academic centers, most with dedicated melanoma clinics. This report describes the initial experience with SLND at a community hospital. Fifteen patients with intermediate-thickness primary cutaneous melanoma underwent preoperative lymphoscintigraphy with 99Tc-sulfur colloid. In addition, intraoperative lymphatic mapping using intradermally injected isosulfan blue was performed. Dissection was guided by radioactivity levels (in counts per second) as measured by a hand-held gamma probe. The resected lymph node or nodes were evaluated for micrometastases using routine hematoxylin and eosin staining and immunohistochemistry with S-100 and HMB-45. All patients were followed clinically for any evidence of recurrence. A sentinel node(s) was identified on preoperative lymphoscintigraphy in all 15 patients (100%). A single sentinel node was identified in 11 of 15 (73%), two nodes in 3 (20%), and one node in 1 (6.7%). The hand-held gamma probe reading correlated well with the site marked the "hot spot" (600-15,320 cps for the hot spot versus 10-350 cps for background). The sentinel lymph node was successfully identified and resected in all 15 patients. Blue-stained lymphatics and/or lymph nodes were present in 8 of 15 (53%) cases. Histopathology was negative for evidence of occult micrometastases in all patients. At mean follow-up of 221 days, all 15 patients remain with no evidence of disease. The outcomes for mapping and harvesting the sentinel node at a community institution compare favorably with results at major academic institutions. SLND may therefore be offered to patients with intermediate-thickness cutaneous melanoma in the community hospital setting with regional lymph node dissection and adjuvant interferon alpha-2b as options for patients with nodal micrometastases.     

Melanoma thickness and histology predict sentinel lymph node status

BACKGROUND: It remains unclear which patients with melanoma will benefit most from lymphatic mapping and sentinel lymphadenectomy. The purpose of this study is to determine whether primary melanoma histopathologic features could be applied to predict sentinel node status. METHODS: One hundred twelve patients underwent sentinel node biopsy between May 1995 and August 1999. Reported histologic features were assessed for predictive value by univariate and multivariate logistic regression. RESULTS: The sentinel node was located successfully in 105 of the 112 patients (94%). Twenty-one of these 105 patients (20%) had sentinel nodes that were positive for metastatic disease. Multivariate analyses revealed that tumor thickness greater than 1.5 mm (P = 0.01), ulceration (P <0.01), and lymphovascular invasion (P = 0.05) predicted the presence of micrometastases. CONCLUSIONS: The presence of unfavorable histopathology such as ulceration and lymphovascular invasion may identify a group of patients with thin melanomas who would benefit from sentinel lymphadenectomy.     

Lymphatic mapping with sentinel node biopsy in pediatric patients

BACKGROUND/PURPOSE: Lymphatic mapping with sentinel node biopsy is used widely in adult melanoma and breast cancer to determine nodal status without the morbidity associated with elective lymph node dissection. This technique can be used in children to determine lymph node status with limited dissection and accurate interpretation. The authors report their initial experience. METHODS: The charts of patients who underwent lymphatic mapping with sentinel node biopsy were reviewed retrospectively. Lymphoscintigraphy was performed in patients with truncal lesions 24 hours before surgery to determine the draining nodal basin (for surgical mapping). The tumors were injected 1 hour preoperatively with technetium sulfur colloid and in the operating room with Lymphazurin blue. The draining basin was examined using a radioisotope detector. The blue nodes with high counts were localized and removed. If nodal metastases were identified, lymph node dissection was recommended. Four patients were injected only with Lymphazurin blue. RESULTS: Thirteen children (7 girls, 6 boys; mean age, 7 years) underwent lymphatic mapping with sentinel node biopsy. The tumor types were as follows: 8 malignant melanoma (6 extremity, 2 truncal), 1 malignant peripheral nerve sheath tumor, 1 alveolar soft part sarcoma, and 3 rhabdomyosarcoma. A mean of 2.4 nodes (range, 1 to 6) were removed from each patient. Six patients had a positive sentinel node. Formal lymph node dissection was performed on 4 of the 6 patients, 1 of whom had further nodal disease with 2 of 13 nodes containing micrometastases. One of the 6 patients refused lymph node dissection and adjuvant therapy; the final patient had rhabdomyosarcoma, a malignancy for which lymph node dissection is not indicated. Pulmonary metastasis developed 26 months after diagnoses in the patient with alveolar soft part sarcoma and a negative sentinel node. This patient was injected only with Lymphazurin blue at the time of sentinel node biopsy and refused adjuvant therapy. There have been no other recurrences. There were no complications related to lymphatic mapping or sentinel node biopsy. CONCLUSIONS: Lymphatic mapping with sentinel node biopsy, using both technetium-labeled sulfur colloid and Lymphazurin blue, can be performed safely in pediatric skin and soft tissue malignancies. Further study with long-term follow-up will determine the utility and accuracy of this technique in pediatric malignancies.     

Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer?

The small number of nodes harvested with lymphatic mapping and sentinel lymph node (SLN) biopsy has allowed a more detailed pathologic examination of those nodes. Immunohistochemical stains for cytokeratin (CK-IHC) have been used in an attempt to minimize the false negative rate for SLN mapping. This study examines the value of CK-IHC positivity in predicting further lymph node involvement in the axillary basin. From April 1998 through May 1999, 519 lymphatic mappings and SLN biopsies were performed for invasive breast cancer. SLNs were examined by imprint cytology, hematoxylin and eosin (H&E), and CK-IHC. Patients with evidence of metastatic disease by any of the above techniques were eligible for complete axillary node dissection (CAND). The frequency with which these modalities predicted further lymph node involvement in the axillary basin was compared. Of the 519 lymphatic mappings, 39 patients (7.5%) had a CK-IHC-positive-only SLN. Five (12.8%) of these 39 patients had at least 2 SLNs positive by CK-IHC. Twenty-six of the CK-IHC-positive-only patients underwent CAND. Three of these 26 patients (11.5%) had additional metastases identified after CAND. The sensitivity levels with which each modality detected further axillary lymph node involvement were as follows: CK-IHC, 98 per cent; H&E, 94 per cent; and imprint cytology, 87 per cent. A logistic regression to compare the prognostic value of the three modalities was performed. All were significant, with odds ratios of 19.1 for CK-IHC (P = 0.015), 5.3 for H&E (P = 0.033), and 3.86 for imprint cytology (P = 0.0059). These data validate the enhanced detection of CK-IHC for the evaluation of SLNs. Detection of CK-IHC-positive SLNs appears to warrant CAND in patients with invasive breast cancer. However, the therapeutic value of CAND or adjuvant therapies based on CK-IHC-positive SLNs would be best answered by prospective randomized trials.     

Completion axillary lymph node dissection minimizes the likelihood of false negatives for patients with invasive breast carcinoma and cytokeratin positive only sentinel lymph nodes

OBJECTIVE: To document the incidence of metastatic disease in complete axillary lymph node dissections (CALND) of patients with invasive carcinoma after a sentinel lymph node (SLN) biopsy, positive only by immunohistochemical staining for cytokeratin (CK-IHC). METHODS: Sections of all SLNs, negative by routine histology, were immunostained and examined for cytokeratin positive cells. Sections of lymph nodes from CALND specimens were interpreted using routine hematoxylin and eosin (H&E) staining. RESULTS: A total of 409 patients (29.6%) had metastatic disease in at least one sentinel lymph node on H&E examination. Of 971 H&E negative patients, 78 (8.0%) were positive only by CK-IHC. Sixty-two of the CK-IHC positive only patients underwent CALND. Nine of these 62 patients (14.5%) had metastases identified in the CALND specimen. CONCLUSIONS: Because 14.5% of patients with invasive breast cancer and SLNs positive only by CK-IHC were found to have H&E positive lymph nodes on CALND, we conclude first, that CK-IHC should be used to evaluate SLNs, and second, that CALND should be considered when SLNs are positive by CK-IHC only. This approach will result in an absolute reduction of the false negative rate (absolute false negative rate reduced by 2.6% in our series).     

CK19表达及其在结肠癌淋巴结微转移诊断中的应用

目的：研究用免疫组化方法检测CK19及其在结肠癌淋巴结微转移诊断中的应用与临床病理意义。方法：取材于50例结肠癌病人肿瘤组织及癌周淋巴结255枚,同时进行HE染色组织学检查和抗角蛋白19抗体的免疫组化检测。结果：50例结肠癌组织中CK19表达均为阳性。255枚淋巴结用HE染色检查阳性者56枚(22．0％),皆同时表达CK19阳性;另20枚淋巴结HE染色阴性,而CK19表达阳性。50例中有12例淋巴结中发现微转移,其中6例常规组织学检查属淋巴结转移阴性而免疫组化染色诊断表现为转移阳性。占常规病理检查淋巴结转移阴性者的21．4％(6／28)。随着肿瘤分期增加,淋巴结CK19表达阳性率亦增加。CK19表达阳性者预后较阴性者为差。结论：CK19免疫组化法是检测结肠癌淋巴结微转移的敏感而便捷的方法,而检测结肠癌微转移有助于判断肿瘤进展程度与预后。特别对在筛选组织学检查淋巴结阴性但存在微转移的病人有实用价值。     

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

BACKGROUND: Frozen section and intraoperative imprint cytology (IIC(N)) are 2 methods used for intraoperative pathologic assessment of sentinel lymph nodes (SLNs). The SLN evaluation of patients with invasive lobular carcinoma (ILC) results in a relatively high number of false-negative results using either of these methods. The purpose of this study was to evaluate the added benefits that intraoperative immunohistochemical-cytokeratin staining (I(CK-IHC)) can bring to IIC(N) in the evaluation of SLN in patients with ILC. METHODS: A total of 59 breast cancer patients with ILC underwent an SLN biopsy evaluated by our standard IIC(N) assessment in addition to I(CK-IHC). The results of IIC(N) with I(CK-IHC) were compared with the final histopathologic assessment consisting of standard hematoxylin and eosin staining and additional cytokeratin staining of nodes. RESULTS: Intraoperative evaluation of SLN using IIC(N) and I(CK-IHC) correctly diagnosed the nodal status in 45 of 59 (76.3%) patients. On final histopathologic assessment, 31 of 59 (52.5%) patients were found to have positive nodes. Using I(CK-IHC), 17 of these 31 positive cases (54.8%) were detected.Using IIC(N) alone, without the benefit of I(CK-IHC), only 13 of 31 (41.9%) positive cases were detected intraoperatively. CONCLUSIONS: For patients with ILC, I(CK-IHC) staining in addition to IIC(N) improves accuracy over using IIC(N) alone. In this study, I(CK-IHC) staining demonstrated a 12.9% improvement in the detection of SLN metastases in patients with ILC. Cytopathologists should consider employing I(CK-IHC) staining to evaluate the touch-imprint slides of SLN in ILC patients.     

A novel lymphatic mapping technique to improve localization and staging of early colon cancer during laparoscopic colectomy

Encouraging results from our previous studies of sentinel lymph node (SLN) mapping in colorectal cancer (CRC) prompted investigation of its feasibility and accuracy during laparoscopic colectomy for early CRC. Between 1996 and 2000, 14 patients with clinically localized colorectal neoplasms underwent colonoscopic tattooing of the primary site and SLN mapping. In each case 0.5 to 1 cm3 of isosulfan blue dye was injected submucosally via the colonoscope. The blue-stained lymphatics were visualized through the laparoscope and followed to the SLN, which was marked with a clip, and laparoscopic colectomy was completed in the routine fashion. All lymph nodes were examined by hematoxylin and eosin (H&E) staining; in addition each SLN was subjected to focused examination by multisectioning and immunohistochemical staining using cytokeratin antibody. In all 14 patients the primary neoplasm and an SLN were identified laparoscopically. An average of 13.5 total lymph nodes and 1.7 SLNs per patient were identified. The SLN correctly reflected the tumor status of the nodal basin in 93 per cent of the cases. In four cases with unexpected lymphatic drainage, the extent of mesenteric resection was altered. In two cases (14%), nodal involvement was micrometastatic, confined to an SLN, and identified only by immunohistochemical staining. Lymphatic mapping caused no complications and added only 10 to 15 minutes to the overall operative time. Comparison of results in this group with results for a matched group of 14 patients undergoing SLN mapping during open colon resection showed that the laparoscopic technique had similar rates of accuracy and success. These preliminary findings indicate that colonoscopic/laparoscopic SLN mapping during laparoscopic colon resection is a feasible and technically simple means of identifying the primary colorectal neoplasm and its SLN. Focused pathologic examination of this node can upstage CRC and thereby may improve selection of patients for adjuvant chemotherapy.     

Lymphatic mapping and focused analysis of sentinel lymph nodes upstage gastrointestinal neoplasms

BACKGROUND: Lymph node analysis is essential for staging gastrointestinal (GI) neoplasms. Intraoperative lymphatic mapping and sentinel lymphadenectomy were originally described for melanoma but have not yet been investigated for most GI neoplasms. HYPOTHESES: (1) Lymphatic mapping and sentinel lymphadenectomy is feasible in GI neoplasms, (2) the sentinel node (SN) status reflects the regional node status, and (3) focused analysis of the SN improves staging accuracy. DESIGN: Prospective patient series. PATIENTS AND METHODS: Lymphatic mapping was performed in 65 patients with GI neoplasms by injecting 0.5 to 1 mL of isosulfan blue dye around the periphery of the neoplasm. Blue-stained SNs were analyzed by hematoxylin-eosin staining, multiple sectioning, and cytokeratin immunohistochemistry. RESULTS: Lymphatic mapping identified at least 1 SN in 62 patients (95%). Of the 36 cases with nodal metastasis, 32 (89%) had at least 1 positive SN and 15 (42%) had nodal metastasis only in the SN. In 11 cases, tumor deposits were identified by multiple sectioning (n = 2) or immunohistochemistry (n = 9) only. In 5 cases (8%), lymphatic mapping identified aberrant lymphatic drainage that altered the extent of the lymphadenectomy. CONCLUSIONS: Lymphatic mapping and sentinel lymphadenectomy are feasible in GI neoplasms and identify aberrant lymphatic drainage. The SN status accurately reflects the regional node status. Focused analysis of the SN increases the detection of micrometastases and may improve selection of patients for adjuvant treatment.     

Detection of lymphatic invasion in early stage primary colorectal cancer with the monoclonal antibody D2-40

PURPOSE: The purpose of this study was to investigate the presence of lymphatic invasion detected by D2-40 immunostaining compared to conventional hematoxylin-eosin (HE) staining in primary colorectal cancer (CRC) and the development of focal new lymphangiogenesis and peritumoral lymphatic proliferation in relation to the tumor stages. Additionally, we analyzed the relation of peritumoral inflammatory reaction (PIR) to tumor stages in CRC. The identification of new categories of patients with high-risk CRC would be very helpful in improving treatment strategies and patient outcome especially in early CRC. PATIENTS AND METHOD: Biopsies were taken from 41 patients with colorectal adenocarcinomas at different stages of disease. Immunohistochemistry was performed on paraffin-embedded sections. First, the whole section was screened for the presence of lymphatic invasion and PIR with routine HE staining. After analysis of the HE-stained slides, the slides were destained and reused for immunohistochemistry with the D2-40 monoclonal antibody. D2-40-immunostained sections were screened for the presence of lymphatic invasion, the proliferation of lymphatic vessels and focally newly developed lymph vessels. RESULTS: Using the D2-40 antibody for immunostaining, our results demonstrate a significantly higher detection (p < 0.05) of lymphatic vessel invasion compared to routine HE staining in primary CRC. 22% more patients with lymphatic vessel invasion could be identified compared to routine HE staining, especially in node-negative tumor stage (UICC II). The positive predictive value of lymphatic invasion evaluated by D2-40 immunostaining to predict lymph node metastasis is 92% (negative predictive value 81%). High PIR was shown in UICC stage I and II. These infiltrations were rarely seen in UICC stage III and were absent in UICC stage IV. Higher UICC tumor stage is associated with a higher rate of focally newly developed lymphatic vessels. In UICC stage I we found peritumoral lymphatic vessel proliferation only in one case (14%) and in UICC stage II no case was found. 47% of the cases in UICC stage III and 50% of the cases in UICC stage IV showed focal peritumoral lymphatic vessel proliferation. CONCLUSIONS: Immunostaining with D2-40 significantly increased the detection rate of lymphatic invasion compared to conventional HE staining in primary CRC. The D2-40 antibody specific for lymphatic endothelium cells has the potential for a prognostic marker in early stage CRC. Further prospective studies are necessary to evaluate the prognostic value of lymphatic invasion and the induction of tumor lymphangiogenesis and its role in human cancer progression.     

Prospective multicenter trial of staging adequacy in colon cancer: preliminary results

HYPOTHESIS: Lymph node evaluation is an important prognostic factor in colorectal cancer (CRC). A 25% recurrence rate in patients with node-negative CRC suggests that current staging practices are inadequate. Focused analysis of the sentinel node (SN) by multiple sectioning and immunohistochemistry improves staging accuracy. DESIGN: Prospective phase 2 multicenter trial. SETTING: Tertiary referral cancer centers. PATIENTS: Between March 2001 and June 2005, 132 patients were enrolled with clinical stage I and II CRC in a prospective multicenter trial (R01-CA90484). INTERVENTION: During a standard oncologic resection, lymphatic mapping was performed and the SN identified either by the surgeon or the pathologist. Hematoxylin-eosin staining was performed on all lymph nodes and immunohistochemistry, on lymph nodes negative by hematoxylin-eosin staining. MAIN OUTCOME MEASURES: Micrometastases greater than 0.2 mm but less than 2 mm and isolated tumor cells less than 0.2 mm were defined according to the sixth edition of the American Joint Committee on Cancer Cancer Staging Manual. RESULTS: The 63 men and 69 women had a median age of 74 years. Sixty-eight patients (52%) underwent a right hemicolectomy; 3 (2.3%), a transverse colectomy; 9 (7%), a left colectomy; 15 (11%), a sigmoid colectomy; 34 (26%), a low anterior resection; 1 (1%), an abdominal perineal resection; and 2 (2%), a total colectomy. Of the 111 evaluable primary tumors, 19 (17%) were T1 lesions; 17 (15%), T2; 72 (65%), T3; and 3 (2.7%), T4 tumors. Thirty-three patients (30%) were classified as stage I; 46 (41%), stage II, and 32 (29%), stage III. The SN was identified by the surgeon in 127 patients (96%) and by the pathologist in 5 patients (4%). The median number of SNs and total lymph nodes examined were 3 and 14.5, respectively. The sensitivity of lymphatic mapping and SN analysis was 88.2% and the false-negative rate, 7.4% (6/81). Of the 6 false-negative results, 4 were attributed to lymphatic channels obliterated by tumor. Upstaging occurred in 28 patients (23.6%). CONCLUSIONS: In a multicenter trial, ultrastaging of colon cancer is feasible and accurate. In stage II CRC, 24% of patients had nodal carcinoma cells not detected by conventional staging methods. Surgical technique (adequate lymph node retrieval) and focused pathological analysis may improve staging accuracy and the selection of patients for chemotherapy. The unnecessary toxicity and expense of chemotherapy may be avoided in those patients who are truly node negative.