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   

Rapid immunohistochemistry of sentinel lymph nodes for metastatic melanoma

Sentinel lymph node (SLN) biopsy is performed on patients with malignant melanoma (MM) to assess the need for selective complete lymphadenectomy. Melanoma metastasis to regional lymph nodes is an important prognostic indicator in patients with MM. This study assesses the sensitivity and specificity of rapid immunohistochemistry (RIHC) in intraoperative delineation of melanoma metastasis to SLN. RIHC for S-100 protein, HMB45, and a melanoma marker cocktail (melan A, HMB45, and tyrosinase) was performed on 71 SLNs obtained from 28 patients with MM. Frozen sections (6 micro thick) on plus slides were fixed for 2 to 3 minutes in cold acetone and then stored at -70 degrees C. The EnVision kit (Dako, Carpinteria, CA) for rapid immunohistochemistry (RIHC) on frozen tissue sections was used, and the staining technique took 19 minutes. Together with preparation of the frozen sections and fixation in acetone, immunostained slides were available in approximately 25 minutes. Of the 71 SNLs examined, 7 showed melanoma metastasis in permanent sections. RIHC of frozen sections detected metastatic melanoma in 6 SLNs, with a sensitivity of 86% for HMB45 and 71% for S-100 protein and the melanoma cocktail and a specificity of 97% for HMB45 and 100% for S-100 and the melanoma cocktail. We conclude that RIHC for HMB45, S-100 protein, and the melanoma cocktail may help detect melanoma metastasis in SLN intraoperatively, leading to total lymph node dissection and obviating the need for 2 surgical procedures. Section folds and background stain can make interpretation difficult. Intraoperative time constraints require a more rapid technique. A recent consensus group has discouraged frozen-section examination of SLN.     

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.     

Pathologic evaluation of sentinel lymph nodes in colorectal carcinoma

BACKGROUND: The identification of lymph node metastases in colorectal resection specimens is necessary for accurate tumor staging. However, routine lymph node dissection by the pathologist yields only a subset of nodes removed surgically and may not include those nodes most directly in the path of lymphatic drainage from the tumor. Intraoperative mapping of such sentinel lymph nodes (SLNs) has been reported in cases of melanoma and breast cancer. We applied a similar method to cases of colorectal carcinoma, with emphasis on the pathology of the SLNs. METHODS: Eighty-three consecutive patients with colorectal carcinoma were evaluated after intraoperative injection of 1 to 2 mL of 1% isosulfan blue dye (Lymphazurin) into the peritumoral subserosa. Blue-stained lymph nodes were suture-tagged by the surgeon within minutes of the injection for identification by the pathologist, and a standard resection was performed. Designated SLNs were sectioned at 10 levels through the block; a cytokeratin immunostain (AE1) was also obtained. To evaluate the possibility that increased detection of metastases in the SLN might be solely due to increased histologic sampling, all initially negative non-SLNs in the first 25 cases were sectioned also at 10 levels. RESULTS: Sentinel lymph nodes were identified intraoperatively in 82 (99%) of 83 patients and accounted for 152 (11.9%) of 1275 lymph nodes recovered, with an average of 1.9 SLNs per patient. A total of 99 positive lymph nodes (38 positive SLNs and 61 positive non-SLNs) were identified in 34 node-positive patients. The SLNs were the only site of metastasis in 17 patients (50%), while 14 patients (41%) had both positive SLNs and non-SLNs. Three patients (9%) had positive non-SLNs with negative SLNs, representing skip metastases. In patients with positive SLNs, 91 (19%) of 474 total lymph nodes and 53 (12%) of 436 non-SLNs were positive for metastasis. In patients with negative SLNs, 8 (1%) of 801 total lymph nodes and 8 (1.2%) of 687 non-SLNs were positive for metastasis. Multilevel sections of 330 initially negative non-SLNs in the first 25 patients yielded only 2 additional positive nodes (0. 6%). All patients with positive SLNs were correctly staged by a combination of 4 representative levels through the SLN(s) together with a single cytokeratin immunostain. CONCLUSIONS: Intraoperative mapping of SLNs in colorectal carcinoma identifies lymph nodes likely to contain metastases. Focused pathologic evaluation of the 1 to 4 SLNs so identified can improve the accuracy of pathologic staging.     

Assessment of sentinel lymph nodes for breast cancer

Sentinel lymph node biopsy is standard of care for assessment of lymph node stage in early breast cancer in patients with clinically negative nodes. The limited clinical significance of low volume axillary metastatic disease has led to changes in surgical management of the axilla with a shift away from routine axillary lymph node dissection if the sentinel lymph node is found to contain metastatic tumour. This has led to a decrease in the use of intraoperative assessment of sentinel nodes. Specimen handling and histological assessment of sentinel lymph nodes is described, with the emphasis on identification of macrometastatic disease defined as metastases greater than 2 mm. Routine levels and/or cytokeratin immunohistochemistry is not recommended. The increasing use of neoadjuvant chemotherapy and growing evidence that sentinel lymph node biopsy is safe and accurate in this setting, including in patients with proven node positive disease, has resulted in new challenges in the interpretation of these specimens.     

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.     

Processing of sentinel lymph nodes for detection of metastatic melanoma

Within the last years, evaluation of sentinel lymph nodes (SLN) has become the most popular method of early staging of several malignancies, including breast carcinoma and melanoma. Because SLN are reportedly the lymph nodes most likely to contain metastatic deposits, identification of such nodes allows pathologists to examine the tissue in a much more intense manner than with the usual lymphadenectomy specimens containing multiple lymph nodes. However, there is not a universally accepted standard protocol for pathologic processing of the SLN. Initially, the most popular protocols called for bisection of the SLN and examination of serial sections, with or without routinely performed immunohistochemistry. Lately, other protocols have been proposed to try to simplify the histologic analysis while providing at least equivalent results. Here we review the different protocols used for the evaluation of SLN and describe the protocol currently in use at M. D. Anderson Cancer Center (Houston, TX).     

Prevalence of occult metastases in axillary sentinel lymph nodes of breast carcinoma

Recently, sentinel lymph node biopsy (SLNB) has been accepted as a standard method of assessment of axillary lymph nodes in breast cancer patients with no clinical lymphadenopathy. There is no standard pathologic method to evaluate sentinel lymph nodes. The purpose of this study is to evaluate the frequency of occult lymph node metastasis in sentinel lymph nodes via serial sectioning and immunohistochemical study with cytokeratin and its relationship with other clinicopathologic factors. Paraffin-embedded blocks of axillary sentinel lymph nodes of breast cancer patients, biopsied in 2005-2009 and reported as negative, were reviewed with 3 μm sections, H and E staining and immunohistochemical study with an epithelial cytokeratin marker. Clinicopathologic data and relapse, if occurred was recorded and its relationship with occult metastasis was statistically analyzed. Sixty-eight sentinel pathology blocks of 66 patients (65 women and one man, median age 49 years) were investigated. Four cases (5.8%) of occult metastases were found, one by HE staining, and three cases with IHC (1 micrometastasis, 2 isolated tumor cells). Accuracy of reported cases was 94.1% upon re-examination. Sixty-four patients were followed after surgery and adjuvant therapy (range: 6-38 months, median: 21 months). No relapse was reported. There was no significant statistical relationship between occult metastasis and disease-free survival. Although 4 cases (5.8%) of sentinel lymph nodes were positive in the complementary study, with a median follow-up of 21 months, we found no difference in disease-free survival between these patients and others. To show a significant, however small, difference, one needs further research with a greater number of patients and longer follow-up.     

Evaluation of sentinel lymph nodes in breast cancer

Sentinel lymph node biopsy is an accurate method for the detection of axillary metastases in cases of breast carcinoma and is of value as a replacement for axillary dissection. There is variation, however, in the methods and protocols used for the histopathological evaluation of sentinel lymph nodes, standardisation of which will be required if results of sentinel lymph node analysis are to be used to stratify patients into prognostic groups. The significance of micrometastases, isolated tumour cells (ITCs) and the value of immunohistochemistry are also matters for further definition. In this Expert Opinion we present reviews from two authors, providing American and European perspectives on the approach to sentinel lymph node evaluation.     

Reliability of intraoperative frozen section and imprint cytological investigation of sentinel lymph nodes in breast cancer

AIMS: The sentinel lymph node procedure enables selective targeting of the first draining lymph node, where the initial metastases will form. A negative sentinel node (SN) predicts the absence of tumour metastases in the other regional lymph nodes with high accuracy. This means that in the case of a negative SN, regional lymph node dissection is no longer necessary. Besides saving costs, this will prevent many side-effects of lymph node dissection. The aim of this study was to evaluate the reliability of intraoperative cytological and frozen section investigation of the SN to detect metastases. This would allow the axillary lymph node dissection to be performed in the same session as the SN procedure and the excision of the primary tumour in case of a positive SN. METHODS AND RESULTS: Seventy-four SNs were detected by gamma probe detection of nanocolloid and visual localization of Patent Blue accumulations in 54 women with stage T1-2N0M0 invasive breast cancer. The identified SN were immediately investigated by frozen section and imprint cytological investigation. Diagnoses were confirmed on the paraffin material, and in case of negative frozen section and paraffin haematoxylin and eosin sections, skip sections and immunohistochemistry were performed. Thirty-one SNs (42%) contained metastases, of which 27 were detected by the frozen section procedure (sensitivity 87%). There were no false positives (specificity 100%). The sensitivity of the imprints was 62% with a specificity of 100%. When evaluating the data per patient, for the frozen section procedure the sensitivity was 91% and the specificity 100%, and for the imprints, the sensitivity was 63% and the specificity 100%. There were no SNs in which the imprints showed metastases and the frozen section did not. CONCLUSIONS: Intraoperative frozen section analysis is a reliable procedure by which a high percentage of sentinel lymph node metastases can be detected in breast cancer patients without false positive results. This allows the surgeon to perform an immediate axillary lymph node dissection in case of positive SNs. In up to 10% of cases, the final paraffin sections will reveal micrometastases that were not detected by the frozen section, and in these patients axillary lymph node dissection will have to be performed in a second session. The imprint method is significantly less sensitive than the frozen section but may be used as an alternative when frozen section is not possible.     

Intraoperative evaluation of sentinel lymph nodes in breast carcinoma by imprint cytology,frozen section and rapid immunohistochemistry

Sentinel lymph nodes (SLN) isolated in 40 patients of breast carcinoma (stage T₁/T₂) were evaluated intraoperatively by imprint cytology and frozen section. Rapid immunohistochemistry (IHC) was done in cases where both imprint smears and frozen sections were negative for any metastatic tumor deposits. The results of these different techniques were compared with postoperative paraffin sections taken as “Gold Standard.” Nottingham modification of Bloom Richardson scoring system was used for grading the tumors. Further, the correlation of the SLN status with tumor size, grade, and lymphovascular invasion was studied. The sensitivity, specificity, and overall accuracy of imprint cytology were 91.7, 100, and 95% respectively, and those of the frozen section were 95.8, 100, and 97.5% respectively. Examination of multiple serial sections improved the sensitivity and overall accuracy of frozen section. Results of intraoperative rapid IHC were equivalent to final paraffin sections. Histological grade and lymphovascular invasion were in direct correlation with SLN metastasis (P < 0.05). The risk of lymphovascular invasion increased from 22.2% in grade I tumors to 85.7% in grade III tumors. SLN biopsy is a reliable method to evaluate the status of the axillary lymph nodes. Imprint cytology can be used reliably where the facility of frozen section is not available. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Serological reagents for the immunohistochemical analysis of melanoma metastases in sentinel lymph nodes

For the immunohistochemical analysis of melanoma, various serological reagents are available. Melanocyte differentiation markers are reactive with cells and tumors of melanocytic lineage. HMB45 to gp100 has been the most commonly used melanocyte differentiation marker. Recently it was complemented by reagents such as antibodies to Melan-A/MART-1 and tyrosinase. Other reagents, whose reactivity is not strictly confined to melanocyte differentiation antigens, are also commonly used. Among them, the most prominent is S100. Other reagents are D5 to MITF or PNL-2. The properties of these reagents are presented, and their usefulness as markers in the setting of metastatic melanoma in sentinel lymph nodes is discussed.     

Mapping metastases in sentinel lymph nodes of breast cancer

Localization of metastases within the sentinel lymph nodes (SLNs) of breast cancer has not been studied. Forty SLNs from 36 patients with operable primary breast cancers were identified by means of lymphatic mapping with patent blue dye. The junction between the patent blue-stained lymphatic vessel draining the tumor and the SLN was labeled with alcian blue. Metastases within the serially sectioned SLNs were assigned to the alcian blue-labeled side, to the opposite side of the virtually halved nodes, or both. Eight SLNs were negative for metastasis. Eleven SLNs had metastases only in the blue half. Only 4 cases had larger metastases in the nonblue half. Metastases are more likely to be located in the vicinity of the inflow junction of the identifiable lymphatic draining the tumor and the SLN. This should be considered when SLNs are examined, especially when they are halved for different studies.     

Use of intraoperative stereomicroscopy for preventing loss of metastases during frozen sectioning of sentinel lymph nodes in breast cancer

Aims:  Optimal detection of metastases in sentinel lymph nodes (SLN) remains controversial. To determine the reliability of intraoperative frozen sections, SLN protocol with one frozen section was compared with macroscopic SLN evaluation with consecutive complete SLN embedding.
Methods and results:  SLN from 135 consecutive breast cancer patients were analysed under a sereomicroscope. Frozen sections were performed in suspicious or clearly involved SLN on cut surface. One control group ( n  = 143) underwent one intraoperative frozen section on each SLN. The second control group ( n  = 90) was subjected to stereomicroscopy and one intraoperative frozen section on each SLN. A conventional SLN protocol with cytokeratin immunohistochemistry was performed postoperatively in all cases. All groups were statistically comparable. In the study group metastases were suspected in 21 SLN (16%) under the stereomicroscope and all were confirmed histologically. The negative SLN rate was significantly lower in the study group than in the main control group (47% versus 64%, P  = 0.008), suggesting loss of metastases during frozen sections. More macrometastases were detected in the study group (30% versus 15%, P  = 0.006); there were no differences in isolated tumour cells or micrometastases. The false-negative rate was significantly lower in the control groups (29% versus 13% and 12%, P  = 0.001).
Conclusions:  Frozen sections potentially lead to loss or reduced size of metastatic deposits in SLN. Avoiding intraoperative frozen sections on grossly inconspicuous SLN may therefore be justified.     

The value of cytokeratin immunohistochemistry in the evaluation of axillary sentinel lymph nodes in patients with lobular breast carcinoma

BACKGROUND: Cytokeratin immunohistochemistry (IHC) reveals a higher rate of occult lymph node metastases among lobular carcinomas than among ductal breast cancers. IHC is widely used but is seldom recommended for the evaluation of sentinel lymph nodes in breast cancer patients. Objective: To assess the value of cytokeratin IHC for the detection of metastases in sentinel lymph nodes of patients with invasive lobular carcinoma. METHODS: The value of IHC, the types of metastasis found by this method, and the involvement of non-sentinel lymph nodes were analysed in a multi-institutional cohort of 449 patients with lobular breast carcinoma, staged by sentinel lymph node biopsy and routine assessment of the sentinel lymph nodes by IHC when multilevel haematoxylin and eosin staining revealed no metastasis. RESULTS: 189 patients (42%) had some type of sentinel node involvement, the frequency of this increasing with increasing tumour size. IHC was needed for identification of 65 of these cases: 17 of 19 isolated tumour cells, 40 of 64 micrometastases, and 8 of 106 larger metastases were detected by this means. Non-sentinel-node involvement was noted in 66 of 161 cases undergoing axillary dissection. Although isolated tumour cells were not associated with further lymph node involvement, sentinel node positivity detected by IHC was associated with further nodal metastases in 12 of 50 cases (0.24), a proportion that is higher than previously reported for breast cancer in general. CONCLUSIONS: IHC is recommended for the evaluation of sentinel nodes from patients with lobular breast carcinoma, as the micrometastases or larger metastases demonstrated by this method are often associated with a further metastatic nodal load.