Is routine intraoperative frozen-section examination of sentinel lymph nodes in breast cancer worthwhile?

Predictive nomogram based on serum tumor markers and clinicopathological features for stratifying lymph node metastasis in breast cancer

BACKGROUND

This study was aimed to establish the nomogram to predict patients' axillary node status by using patients' clinicopathological and tumor characteristic factors.

METHODS

A total of 705 patients with breast cancer were enrolled in this study. All patients were randomly divided into a training group and a validation group. Univariate and multivariate ordered logistic regression were used to determine the predictive ability of each variable. A nomogram was performed based on the factors selected from logistic regression results. Receiver operating characteristic curve (ROC) analysis, calibration plots and decision curve analysis (DCA) were used to evaluate the discriminative ability and accuracy of the models.

RESULTS

Logistic regression analysis demonstrated that CEA, CA125, CA153, tumor size, vascular-invasion, calcification, and tumor grade were independent prognostic factors for positive ALNs. Integrating all the predictive factors, a nomogram was successfully developed and validated. The C-indexes of the nomogram for prediction of no ALN metastasis, positive ALN, and four and more ALN metastasis were 0.826, 0.706, and 0.855 in training group and 0.836, 0.731, and 0.897 in validation group. Furthermore, calibration plots and DCA demonstrated a satisfactory performance of our nomogram.

CONCLUSION

We successfully construct and validate the nomogram to predict patients' axillary node status by using patients' clinicopathological and tumor characteristic factors.

The diagnostic accuracy of intraoperative frozen section biopsy for diagnosis of sentinel lymph node metastasis in breast cancer patients: a meta-analysis

Sentinel lymph node (SLN) sampling is important for evaluating the nodal stage of breast cancer when the axillary nodes are clinically free of metastasis. The intraoperative frozen section (IFS) of SLN is used for lymph node assessment. This meta-analysis aims to provide evidence about the diagnostic accuracy and the applicability of IFS of SLN in breast cancer patients. Data were collected by searching PubMed, Cochrane, Scopus, and Web of Science electronic databases for trials matching our eligibility criteria. The statistical analysis included the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and pooled studies' diagnostic odds ratio outcomes. The analyses were conducted using the Open Meta-analyst software. This meta-analysis pooled the results of 110 studies. The overall sensitivity of IFS for SLN metastasis was 74.7%; 95% CI [72.0, 77.2], P < 0.001. It was 31.4% 95% CI [25.2, 38.3], P < 0.001 for the micro-metastasis, and 90.2%; 95% CI [86.5, 93.0], P < 0.001 for the macro-metastasis. The overall specificity was 99.4%; 95% CI [99.2, 99.6], P < 0.001. The overall positive likelihood ratio was 121.4; 95% CI [87.9, 167.6], P < 0.001, and the overall negative likelihood ratio was 0.226; 95% CI [0.186, 0.274], P < 0.001. The overall diagnostic odds ratio of IFS for diagnosing SLN metastasis was 569.5; 95% CI [404.2, 802.4], P < 0.001. The intraoperative frozen section of SLN has good sensitivity for diagnosing breast cancer macro-metastasis. However, the sensitivity is low for micro-metastasis. The specificity is very satisfactory.

Differentiation Between Benign and Metastatic Breast Lymph Nodes Using Apparent Diffusion Coefficients

The aim of this study was to determine the range of apparent diffusion coefficient (ADC) values for benign axillary lymph nodes in contrast to malignant axillary lymph nodes, and to define the optimal ADC thresholds for three different ADC parameters (minimum, maximum, and mean ADC) in differentiating between benign and malignant lymph nodes. This retrospective study included consecutive patients who underwent breast MRI from January 2017–December 2020. Two-year follow-up breast imaging or histopathology served as the reference standard for axillary lymph node status. Area under the receiver operating characteristic curve (AUC) values for minimum, maximum, and mean ADC (min ADC, max ADC, and mean ADC) for benign vs malignant axillary lymph nodes were determined using the Wilcoxon rank sum test, and optimal ADC thresholds were determined using Youden’s Index. The final study sample consisted of 217 patients (100% female, median age of 52 years (range, 22–81), 110 with benign axillary lymph nodes and 107 with malignant axillary lymph nodes. For benign axillary lymph nodes, ADC values (×10⁻³ mm²/s) ranged from 0.522–2.712 for mean ADC, 0.774–3.382 for max ADC, and 0.071–2.409 for min ADC; for malignant axillary lymph nodes, ADC values (×10⁻³ mm²/s) ranged from 0.796–1.080 for mean ADC, 1.168–1.592 for max ADC, and 0.351–0.688 for min ADC for malignant axillary lymph nodes. While there was a statistically difference in all ADC parameters (p<0.001) between benign and malignant axillary lymph nodes, boxplots illustrate overlaps in ADC values, with the least overlap occurring with mean ADC, suggesting that this is the most useful ADC parameter for differentiating between benign and malignant axillary lymph nodes. The mean ADC threshold that resulted in the highest diagnostic accuracy for differentiating between benign and malignant lymph nodes was 1.004×10⁻³ mm²/s, yielding an accuracy of 75%, sensitivity of 71%, specificity of 79%, positive predictive value of 77%, and negative predictive value of 74%. This mean ADC threshold is lower than the European Society of Breast Imaging (EUSOBI) mean ADC threshold of 1.300×10⁻³ mm²/s, therefore suggesting that the EUSOBI threshold which was recently recommended for breast tumors should not be extrapolated to evaluate the axillary lymph nodes.

Axillary management based on American college of surgeons oncology group Z0011 criteria makes it possible to omit intraoperative diagnosis of sentinel lymph nodes in early breast cancer patients

The ACOSOG Z0011 trial has resulted in the omission of axillary lymph node dissection (ALND) in early breast cancer patients with one or two metastatic sentinel lymph nodes (SLNs). There has been increasing interest in the necessity of intraoperative assessment of SLNs in patients treated based on the Z0011 criteria. We evaluated the utility of intraoperative assessment in these eligible patients. A total of 1396 patients were treated following the Z0011 criteria from April 2012 to December 2019. We examined the proportion and clinicopathological features of patients who underwent ALND due to three or more metastatic SLNs and the sensitivity of intraoperative assessment. Only 16 (1.1%) patients had three or more metastatic SLNs diagnosed by intraoperative assessment, and they immediately underwent ALND. Of the clinicopathological factors, high clinical tumor stage (p = 0.002) and high Ki-67 labeling index value (p = 0.056) were more likely to be associated with the presence of three or more metastatic SLNs. The major independent risk factor for three or more metastatic SLNs was high clinical tumor stage (OR 3.94 [95% CI 1.42-11.0]; p = 0.009). Intraoperative assessment had low sensitivity (70.5%) and a high false-negative rate (29.5%) in detecting SLN metastases. The main finding of our study was the small proportion of patients who required ALND due to three or more metastatic SLNs according to the Z0011 criteria. The Z0011 strategy enables intraoperative assessment of SLNs to be omitted in early breast cancer patients.

Quality assurance review: Intra-operative evaluation of sentinel lymph nodes in breast cancer

BACKGROUND

Intraoperative consultation (IOC) of axillary sentinel lymph node (SLN) biopsy continues to play a role in selected breast cancer patients. The reported sensitivity rates for intraoperative SLN evaluation in breast cancer range from 47% to 80%. We study a center where the majority of SLN IOC is performed by imprint cytology, and a protocol was established to limit microscopic examination to three slides for a reporting TAT goal of 30 min.

METHODS

Approval to conduct this study was obtained from the REB. A retrospective review was performed on all consecutive SLN cases sent for IOC. Reported IOC assessments of all cases were compared with the final pathology.

RESULTS

Of 164 patients, there were 22 (13%) false negative IOC events, including 15 missed macro-metastasis and 7 missed micro-metastasis. The overall sensitivity for touch imprint in detecting SLNs macro-metastasis was 70.9%. Reporting total turnaround time was on average 3 min longer, whereas sensitivity and specificity were not significantly different in the two protocol periods.

CONCLUSION

Implementation of an IOC policy for a maximum of three slides for imprint cytology did not result in a significant impact on the sensitivity, specificity, or total turnaround time for SLN in breast cancer patients. False negative IOC events were mainly due to sampling error. Quality review was made difficult by limited documentation related to the gross handling of the specimens at IOC. System factors identified include insufficient space for the IOC report on the pathology requisition, and the lack of clearly communicated expectations for documentation.

The Guiding Significance of the Number of Positive Sentinel Lymph Nodes in Frozen Section for Intraoperative Axillary Dissection in Early Breast Cancer

Purpose

The results of large randomised trials have changed the treatment strategy of axillary lymph nodes. Axillary lymph node dissection (ALND) can be avoided in some patients with one to two sentinel lymph nodes (SLNs) metastasis based on final paraffin section (FPS) results which called into question the need for intraoperative frozen section (FS). This study aims to assess the guiding value of the number of positive SLN detected via FS for intraoperative ALND.

Patients and Methods

This study retrospectively analyzed data from 3303 patients with breast cancer who underwent SLN biopsy between 2015 and 2019. Combined with the FPS results, FS sensitivity, specificity, and false negative rate (FNR) were calculated and the difference in the number of positive SLNs between FS and FPS was analyzed.

Results

The overall FNR of FS was 23.21%, which was 76.47% in isolated tumor cells, 62.28% in micrometastasis, and 12.09% in macrometastatic disease. The size of SLN metastasis were significantly associated with a higher FNR (p<0.001). The accuracy rate of the number of positive SLNs detected via FS was 92.62%. Human epidermal growth factor receptor 2 (HER2) (p<0.03) and Ki67 (p<0.02) were significant factors affecting the accuracy rate.

Conclusion

FS is a effective method for SLN biopsy, ALND can be avoided in patients with one or two positive SLNs detected via FS.

Intraoperative Detection of Micrometastases in Whole Excised Lymph Nodes Using Fluorescent Paired-Agent Imaging Principles: Identification of a Suitable Staining and Rinsing Protocol

PURPOSE

Correctly identifying nodal status is recognized as a critical prognostic factor in many cancer types and is essential to guide adjuvant treatment. Currently, surgical removal of lymph nodes followed by pathological examination is commonly performed as a standard-of-care to detect node metastases. However, conventional pathology protocols are time-consuming, yet less than 1 % of lymph node volumes are examined, resulting in a 30-60 % rate of missed micrometastases (0.2-2 mm in size).

PROCEDURES

This study presents a method to fluorescently stain excised lymph nodes using paired-agent molecular imaging principles, which entail co-administration of a molecular-targeted imaging agent with a suitable control (untargeted) agent, whereby any nonspecific retention of the targeted agent is accounted for by the signal from the control agent. Specifically, it was demonstrated that by dual-needle continuous infusion of either an antibody-based imaging agent pair (epidermal growth factor receptor (EGFR) targeted agent: IRDye-800CW labeled Cetuximab; control agent: IRDye-700DX-IgG) or an Affibody-based pair (EGFR targeted Affibody® agent: ABY-029; control agent IRDYe-700DX carboxylate) at 0.3 ml/min.

RESULTS

The results demonstrated the possibility to achieve >99 % sensitivity and > 95 % specificity for detection of a single micrometastasis (~0.2 mm diameter) in a whole lymph node within 22 min of tissue processing time.

CONCLUSION

The detection capabilities offer substantial improvements over existing intraoperative lymph node biopsy methods (e.g., frozen pathology has a micrometastasis sensitivity <20 %).

Evaluation of internal mammary lymph node biopsy during microsurgical breast reconstruction: An analysis of 230 consecutive patients

INTRODUCTION

Clinical significance of internal mammary (IM) lymph node biopsy during microvascular free flap breast reconstruction remains controversial. Some microsurgeons may choose to biopsy an IM lymph node during routine IM vessel dissection. The authors reviewed the results of IM lymph node biopsy during autologous breast reconstruction.

METHODS

A retrospective chart review of patients who underwent autologous breast reconstruction during a seven-year period (January 2010 to January 2017) was performed. Patient demographic data, disease staging, flap details, pathology reports, and adjuvant treatment were evaluated.

RESULTS

A total of 230 patients with a mean age of 52.1 (SD 9.3) underwent IM lymph node biopsy (n = 297). Single IM lymph node was removed in 169 patients, 2 nodes were removed in 56 patients, 3 nodes in 4 patients, and 4 nodes in a single patient. Histopathologic analysis demonstrated presence of IM lymph node metastasis in 16 patients (7.0%). Thirteen patients were found to have metastatic IM lymph nodes in the setting of immediate reconstruction. Three patients were found to have metastatic IM lymph nodes in the setting of delayed. Five out of 16 patients (31.3%) had negative axillary sentinel lymph node biopsy and IM lymph nodes were the only site of nodal metastases. All five of these patients were upstaged accordingly and received adjuvant therapy based on the discussion at the multidisciplinary breast tumor conference.

CONCLUSIONS

Opportunistic internal mammary lymph node sampling during autologous breast reconstruction can be performed with minimal morbidity and has significant impact on the disease staging and adjuvant treatment.

Is the intraoperative frozen section analysis of sentinel lymph nodes necessary in clinically negative node breast cancer?

Purpose

Although metastasis occurs in 1 or 2 sentinel lymph nodes (SLNs), axillary lymph node dissection (ALND) has been widely not performed. For axillary staging and management, the necessity of intraoperative frozen section analysis of SLN has been controversial. The aim of this study is to evaluate the validity and benefit of SLN analysis by permanent section alone in clinically negative lymph node breast cancer patients.

Methods

We conducted a retrospective study of 283 cases with negative node clinical findings between July 2018 and August 2019 in Samsung Medical Center. Clinical nodal stage was evaluated by physical examination, breast ultrasonography, breast magnetic resonance imaging, and chest computerized tomography. The cases were divided into 2 groups; the permanent group had 151 cases (53.4%) and the frozen group had 132 cases (46.6%). We retrospectively analyzed the differences in the number of metastatic lymph nodes and rates of performed ALND between the 2 groups.

Results

Baseline and clinicopathologic characteristics between the 2 groups were well balanced. Three cases in the permanent group and 6 cases in the frozen group underwent additional or immediate ALND. The rates of ALND between the 2 groups were not significantly different (P = 0.312). The cased of 78.9% and 89.5% with metastatic lymph nodes in permanent and frozen groups were in the pathologic N1 stage, respectively.

Conclusion

SLNs analysis by permanent section alone may be performed in clinically negative axillary node breast cancer patients. Our findings can help to avoid unnecessary intraoperative frozen section analysis.

Diagnostic criteria of sentinel lymph node micrometastasis or macrometastasis based on tissue rinse liquid-based cytology in gynecological cancer

OBJECTIVE

This study aimed to establish intraoperative diagnostic criteria of sentinel lymph node (SLN) micro-/macrometastasis on the basis of tissue rinse liquid-based cytology (TRLBC) in gynecological cancer.

METHODS

We enrolled 214 patients with gynecological cancer who underwent rapid diagnosis of SLN metastasis on the basis of TRLBC from a total of 490 SLNs. For slides that were classified as positive for atypical cells on cytological inspection, we counted the number of clusters (an atypical cell mass consisted of three or more cells) and the number of single cells (an atypical cell other than clusters). Receiver operating characteristic (ROC) analysis was applied to determine the efficiency of predicting SLN micro-/macrometastasis.

RESULTS

On cytological inspection, 36 slides were classified as positive for atypical cells, while 21 slides (4.3%) were true positive, 15 (3.1%) were false positive, and 454 (92.6%) were true negative. There were no false negative results in this study. The area under the ROC curve for the number of cluster was superior to that for the number of single cells for distinguishing micro-/macrometastasis from negative/isolated tumor cells (0.86 vs. 0.67, P = 0.032). The optimum cut-off value of the number of clusters was 5 for distinguishing these two categories.

CONCLUSIONS

TRLBC is a highly sensitive alternative for detecting SLN metastasis as a rapid intraoperative diagnosis. Counting the number of atypical cell clusters might be useful for distinguishing micro-/macrometastasis from isolated tumor cells.

Practical Applications of Delayed-Immediate Autologous Breast Reconstruction: A Flexible and Safe Operative Strategy

BACKGROUND

Timing is an important consideration in patients undergoing mastectomy for breast cancer. While immediate reconstruction results in superior aesthetic outcomes, the need for postmastectomy radiation can often only be ascertained after review of surgical pathology. Delayed-immediate autologous reconstruction (DIAR) is a reconstructive approach that consists of mastectomy with tissue expander placement in the first stage and flap-based breast reconstruction in the second stage. We describe our institution's experience with DIAR to characterize the reasons in which patients opt for this reconstructive approach and analyze its ultimate outcomes.

METHODS

We conducted an institutional review board-approved retrospective chart review of all consecutive patients undergoing DIAR performed by the senior author from 2007 to 2016. Data gathered included demographics, operative techniques, and postoperative outcomes.

RESULTS

In our study, 17 patients and 26 breasts underwent DIAR. Seven patients initially planned for and eventually underwent DIAR. Ten patients initially planned for implant-based reconstructions but ultimately underwent DIAR instead. Flap types included deep inferior epigastric perforator (n = 6), superficial inferior epigastric artery (n = 2), and muscle-sparing free transverse rectus abdominis myocutaneous (n = 18). The mean time between mastectomy and reconstruction was 208 days. Complications included tissue expander infection, vascular compromise, abscess formation, hematoma, and skin necrosis.

CONCLUSIONS

The delayed-immediate approach allows for breast reconstruction with aesthetic and psychosocial benefits, while enabling postmastectomy radiation in patients with advanced disease. We describe modifications to DIAR, including use of a flap skin paddle and prolonged time between stages, which allow for broader applicability. We show that DIAR accommodates a range of patient preferences with few complications.

Axillary Lymph Node Evaluation Utilizing Convolutional Neural Networks Using MRI Dataset

The aim of this study is to evaluate the role of convolutional neural network (CNN) in predicting axillary lymph node metastasis, using a breast MRI dataset. An institutional review board (IRB)-approved retrospective review of our database from 1/2013 to 6/2016 identified 275 axillary lymph nodes for this study. Biopsy-proven 133 metastatic axillary lymph nodes and 142 negative control lymph nodes were identified based on benign biopsies (100) and from healthy MRI screening patients (42) with at least 3 years of negative follow-up. For each breast MRI, axillary lymph node was identified on first T1 post contrast dynamic images and underwent 3D segmentation using an open source software platform 3D Slicer. A 32 × 32 patch was then extracted from the center slice of the segmented tumor data. A CNN was designed for lymph node prediction based on each of these cropped images. The CNN consisted of seven convolutional layers and max-pooling layers with 50% dropout applied in the linear layer. In addition, data augmentation and L2 regularization were performed to limit overfitting. Training was implemented using the Adam optimizer, an algorithm for first-order gradient-based optimization of stochastic objective functions, based on adaptive estimates of lower-order moments. Code for this study was written in Python using the TensorFlow module (1.0.0). Experiments and CNN training were done on a Linux workstation with NVIDIA GTX 1070 Pascal GPU. Two class axillary lymph node metastasis prediction models were evaluated. For each lymph node, a final softmax score threshold of 0.5 was used for classification. Based on this, CNN achieved a mean five-fold cross-validation accuracy of 84.3%. It is feasible for current deep CNN architectures to be trained to predict likelihood of axillary lymph node metastasis. Larger dataset will likely improve our prediction model and can potentially be a non-invasive alternative to core needle biopsy and even sentinel lymph node evaluation.

Detection of breast cancer lymph node metastases in frozen sections with a point-of-care low-cost microscope scanner

Background

Detection of lymph node metastases is essential in breast cancer diagnostics and staging, affecting treatment and prognosis. Intraoperative microscopy analysis of sentinel lymph node frozen sections is standard for detection of axillary metastases but requires access to a pathologist for sample analysis. Remote analysis of digitized samples is an alternative solution but is limited by the requirement for high-end slide scanning equipment.

Objective

To determine whether the image quality achievable with a low-cost, miniature digital microscope scanner is sufficient for detection of metastases in breast cancer lymph node frozen sections.

Methods

Lymph node frozen sections from 79 breast cancer patients were digitized using a prototype miniature microscope scanner and a high-end slide scanner. Images were independently reviewed by two pathologists and results compared between devices with conventional light microscopy analysis as ground truth.

Results

Detection of metastases in the images acquired with the miniature scanner yielded an overall sensitivity of 91% and specificity of 99% and showed strong agreement when compared to light microscopy (k = 0.91). Strong agreement was also observed when results were compared to results from the high-end slide scanner (k = 0.94). A majority of discrepant cases were micrometastases and sections of which no anticytokeratin staining was available.

Conclusion

Accuracy of detection of metastatic cells in breast cancer sentinel lymph node frozen sections by visual analysis of samples digitized using low-cost, point-of-care microscopy is comparable to analysis of digital samples scanned using a high-end, whole slide scanner. This technique could potentially provide a workflow for digital diagnostics in resource-limited settings, facilitate sample analysis at the point-of-care and reduce the need for trained experts on-site during surgical procedures.

Multiscale nonlinear microscopy and widefield white light imaging enables rapid histological imaging of surgical specimen margins

The ability to histologically assess surgical specimens in real-time is a long-standing challenge in cancer surgery, including applications such as breast conserving therapy (BCT). Up to 40% of women treated with BCT for breast cancer require a repeat surgery due to postoperative histological findings of close or positive surgical margins using conventional formalin fixed paraffin embedded histology. Imaging technologies such as nonlinear microscopy (NLM), combined with exogenous fluorophores can rapidly provide virtual H&E imaging of surgical specimens without requiring microtome sectioning, facilitating intraoperative assessment of margin status. However, the large volume of typical surgical excisions combined with the need for rapid assessment, make comprehensive cellular resolution margin assessment during surgery challenging. To address this limitation, we developed a multiscale, real-time microscope with variable magnification NLM and real-time, co-registered position display using a widefield white light imaging system. Margin assessment can be performed rapidly under operator guidance to image specific regions of interest located using widefield imaging. Using simulated surgical margins dissected from human breast excisions, we demonstrate that multi-centimeter margins can be comprehensively imaged at cellular resolution, enabling intraoperative margin assessment. These methods are consistent with pathology assessment performed using frozen section analysis (FSA), however NLM enables faster and more comprehensive assessment of surgical specimens because imaging can be performed without freezing and cryo-sectioning. Therefore, NLM methods have the potential to be applied to a wide range of intra-operative applications.

Is Low-Volume Disease in the Sentinel Node After Neoadjuvant Chemotherapy an Indication for Axillary Dissection?

BACKGROUND/OBJECTIVE

Intraoperative evaluation of sentinel lymph nodes (SLNs) after neoadjuvant chemotherapy (NAC) has a higher false-negative rate than in the primary surgical setting, particularly for small tumor deposits. Additional tumor burden seen with isolated tumor cells (ITCs) and micrometastases following primary surgery is low; however, it is unknown whether the same is true after NAC. We examined the false-negative rate of intraoperative frozen section (FS) after NAC, and the association between SLN metastasis size and residual disease at axillary lymph node dissection (ALND).

METHODS

Patients undergoing SLN biopsy after NAC were identified. The association between SLN metastasis size and residual axillary disease was examined.

RESULTS

From July 2008 to July 2017, 702 patients (711 cancers) had SLN biopsy after NAC. On FS, 181 had metastases, 530 were negative; 33 negative cases were positive on final pathology (false-negative rate 6.2%). Among patients with a positive FS, 3 (2%) had ITCs and no further disease on ALND; 41 (23%) had micrometastases and 125 (69%) had macrometastases. Fifty-nine percent of patients with micrometastases and 63% with macrometastases had one or more additional positive nodes at ALND. Among those with a false-negative result, 10 (30%) had ITCs, 15 (46%) had micrometastases, and 8 (24%) had macrometastases; 17 had ALND and 59% had one or more additional positive lymph nodes. Overall, 1/6 (17%) patients with ITCs and 28/44 (64%) patients with micrometastases had additional nodal metastases at ALND.

CONCLUSION

Low-volume SLN disease after NAC is not an indicator of a low risk of additional positive axillary nodes and remains an indication for ALND, even when not detected on intraoperative FS.

Clinical Approaches to Breast Reconstruction: What Is the Appropriate Reconstructive Procedure for My Patient?

Breast reconstruction after breast cancer is an emotional subject for women. Consequently, the correct timing and surgical procedure for each individual woman are important. In general, heterologous or autologous reconstructive procedures are available, both having advantages and disadvantages. Breast size, patient habitus, and previous surgeries or radiation therapy need to be considered, independent of the chosen procedure. New surgical techniques, refinement of surgical procedures, and the development of supportive materials have increased the general patient collective eligible for breast reconstruction. This review highlights the different approaches to immediate breast reconstruction using autologous or heterologous techniques.

Distinct Ezrin Truncations Differentiate Metastases in Sentinel Lymph Nodes from Unaffected Lymph Node Tissues, from Primary Breast Tumors, and from Healthy Glandular Breast Tissues

BACKGROUND

Lymph node metastasis status is a prognostic factor for further lymph node involvement and for patient survival in breast cancer patients. Frozen section analysis of lymph nodes is a reliable method for detection of macro-metastases. However, this method is far less effective in detecting micro-metastases, requesting improved diagnostic procedures.

METHODS

We investigated expression and truncation of ezrin in (i) sentinel lymph node metastases, (ii) unaffected axillary lymph nodes, (iii) primary breast tumors, and (iv) healthy glandular breast tissues using 2D gel electrophoresis, SDS-PAGE, and mass spectrometry in addition to Western blotting.

RESULTS

Full-length ezrin (E1; amino acids 1-586) is present in all four investigated tissues. Two truncated ezrin forms, one missing about the first hundred amino acids (E2a) and the other lacking about 150 C-terminal amino acids (E2b) were detectable in primary tumor tissues and in sentinel lymph node metastases but not in glandular tissues. Strikingly, an ezrin truncation (E3) which consists approximately of amino acids 238-586 was found strongly expressed in all sentinel lymph node metastases. Moreover, an N-terminal ezrin fragment (E4) that consists approximately of amino acids 1-273 was identified in sentinel lymph node metastases as well.

CONCLUSIONS

We show for the first time the existence of tissue-dependent specific ezrin truncations. The distinguished strong Western blot staining of ezrin E3 in sentinel lymph node metastases underlines its capability to substantiate the occurrence of lymph node (micro)metastases in breast cancer patients.

Factors impacting the accuracy of intra-operative evaluation of sentinel lymph nodes in breast cancer

Sentinel lymph node dissection (SLND) is a standard axillary staging technique in breast cancer and intraoperative sentinel lymph node (SLN) assessment is important for decision-making regarding additional treatment and reconstruction. This study was undertaken to investigate clinicopathologic factors impacting the accuracy of intraoperative SLN evaluation. Records of patients with clinically node-negative, invasive breast cancer who underwent SLND with frozen section intraoperative pathologic evaluation from 2004 to 2007 were reviewed. Intraoperative SLN assessment results were compared to final pathology. Patients with positive SLNs that were initially reported as negative during intraoperative assessment were considered false negative (FN) events. Primary tumor histology, grade, receptor status, size, lymphovascular invasion (LVI), multifocality, neoadjuvant chemotherapy or hormonal therapy, number of SLNs retrieved, and SLN metastasis size were evaluated. The study included 681 patients, of whom 262 (38%) received neoadjuvant therapy. There were 183 (27%) patients who had a positive SLN on final pathology, of whom 60 (33%) had FN events. On univariate analysis, lobular histology, favorable histology, absence of LVI and micrometastasis were associated with a higher FN rate. On multivariate analysis, favorable and lobular histology and micrometastasis were independent predictors of FN events whereas LVI and receipt of neoadjuvant therapy were not statistically significant predictors. The accuracy of intraoperative SLN evaluation for breast cancer is affected by primary tumor histology and size of the SLN metastasis. There was no significant association between neoadjuvant therapy and the FN rate by intraoperative assessment. This information may be helpful in counseling patients about their risk for a FN intraoperative SLN assessment and for planning for immediate breast reconstruction in patients undergoing mastectomy.

Can We Skip Intraoperative Evaluation of Sentinel Lymph Nodes? Nomogram Predicting Involvement of Three or More Axillary Lymph Nodes before Breast Cancer Surgery

Purpose

The American College of Surgeons Oncology Group Z0011 trial reported that complete dissection of axillary lymph nodes (ALNs) may not be warranted in women with clinical T1-T2 tumors and one or two involved ALNs who were undergoing lumpectomy plus radiation followed by systemic therapy. The present study was conducted to identify preoperative imaging predictors of ≥ 3 ALNs.

Materials and Methods

The training set consisted of 1,917 patients with clinical T1-T2 and node negative invasive breast cancer. Factors associated with ≥ 3 involved ALNs were evaluated by logistic regression analysis. The validation set consisted of 378 independent patients. The nomogram was applied prospectively to 512 patients who met the Z0011 criteria.

Results

Of the 1,917 patients, 204 (10.6%) had ≥ 3 positive nodes. Multivariate analysis showed that involvement of ≥ 3 nodes was significantly associated with ultrasonographic and chest computed tomography findings of suspicious ALNs (p < 0.001 each). These two imaging criteria, plus patient age, were used to develop a nomogram calculating the probability of involvement of ≥ 3 ALNs. The areas under the receiver operating characteristic curve of the nomogram were 0.852 (95% confidence interval [CI], 0.820 to 0.883) for the training set and 0.896 (95% CI, 0.836 to 0.957) for the validation set. Prospective application of the nomogram showed that 60 of 512 patients (11.7%) had scores above the cut-off. Application of the nomogram reduced operation time and cost, with a very low re-operation rate (1.6%).

Conclusion

Patients likely to have ≥ 3 positive ALNs could be identified by preoperative imaging. The nomogram was helpful in selective intraoperative examination of sentinel lymph nodes.

Virtual Hematoxylin and Eosin Transillumination Microscopy Using Epi-Fluorescence Imaging

We derive a physically realistic model for the generation of virtual transillumination, white light microscopy images using epi-fluorescence measurements from thick, unsectioned tissue. We demonstrate this technique by generating virtual transillumination H&E images of unsectioned human breast tissue from epi-fluorescence multiphoton microscopy data. The virtual transillumination algorithm is shown to enable improved contrast and color accuracy compared with previous color mapping methods. Finally, we present an open source implementation of the algorithm in OpenGL, enabling real-time GPU-based generation of virtual transillumination microscopy images using conventional fluorescence microscopy systems.

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.

Intraoperative Frozen Section Evaluation of Sentinel Lymph Nodes in Breast Carcinoma: Single-Institution Indian Experience

Sentinel lymph node biopsy is an established way of predicting axillary nodal metastasis in early breast cancer. Intraoperative frozen sections (FS) of sentinel lymph nodes (SLNs) can be used to detect metastatic disease, allowing immediate axillary lymph node dissection. The purpose of this study was to evaluate the accuracy of intraoperative frozen sections in evaluation of sentinel lymph nodes in cases of breast cancer. Between March 2006 and August 2010, a total of 164 patients with clinically node-negative operable breast cancer were subjected to sentinel lymph node biopsy of axillary lymph nodes using preoperative peritumoral injection of radioactive colloid and methylene blue. Intraoperative identification of sentinel nodes was done using a handheld gamma probe and identification of blue-stained nodes. The nodes were sent for frozen section examination. The results of frozen section were compared with the final histopathology. Out of the 164 cases, metastases were detected in SLN by frozen section in 38 cases. There were three false-negative cases (all showing micrometastasis on final histopathology). FS had sensitivity of 92.6 %, specificity of 100 %, and overall accuracy of 98.1 %. The positive predictive value was 100 %, and the negative predictive value was 97.6 %. FS for diagnosis of metastasis of SLNs is reliable. Patients with negative SLNs by the FS diagnosis can avoid reoperation for axillary lymph node dissection. However, FS may fail to detect micrometastases, especially in cases with small tumors.

Intraoperative detection of sentinel lymph node metastases in breast carcinoma by Fourier transform infrared spectroscopy

Background

Sentinel lymph node (SLN) biopsy is a routine surgical staging procedure in clinically lymph node-negative breast cancer. Fourier transform infrared (FTIR) spectroscopy, a technique based on the biochemical composition of the tissue, has previously been found to be capable of differentiating between normal and malignant tissue. The aim of the present study was to explore the intraoperative use of FTIR spectroscopy for rapidly identifying metastatic SLNs, and distinguishing between metastatic and non-metastatic tissue.

Methods

Freshly removed SLNs from patients with breast cancer were analysed. Samples were measured by FTIR spectroscopy before histopathological diagnosis. The FTIR spectrum of each sample identified ten bands from 2000 to 900 cm−1. The peak position, intensity and full width at half maximum of each absorbent band were measured, and the relative intensity ratios calculated. Canonical discriminant analysis was performed to discriminate between metastatic and non-metastatic samples.

Results

A total of 149 SLNs were removed from 49 patients. Histopathological examination confirmed 38 metastatic and 111 non-metastatic SLNs. Eighteen of 29 parameters were significantly different between the metastatic and non-metastatic SLNs. Five parameters were selected as independent factors to form discriminant functions. The sensitivity, specificity and accuracy of this method were 94·7, 90·1 and 91·3 per cent respectively. The accuracy of histological analysis of frozen sections was 100 per cent.

Conclusion

FTIR spectroscopy is a promising technique for the real-time diagnosis of SLN metastasis during breast cancer surgery. Surgical relevanceSentinel lymph node (SLN) biopsy is a highly accurate predictor of overall axillary status and has become the standard in disease staging in clinically node-negative breast cancer. A rapid and accurate intraoperative assessment of metastatic spread to the SLN provides the necessary information for the surgeon to proceed with immediate axillary dissection.The results of this research indicate that Fourier transform infrared (FTIR) spectroscopy is a rapid, accurate, non-destructive and cost-effective molecular method that can be used to detect SLN metastasis during surgery.FTIR analysis could be useful for the intraoperative diagnosis of lymph node metastases at large institutions, thereby reducing the workload of pathologists, as well as in regions lacking pathologists such as in developing countries.

False negative rate for intraoperative sentinel lymph node frozen section in patients with breast cancer: a retrospective analysis of patients in a single Asian institution

BACKGROUND AND OBJECTIVE

Intraoperative frozen section of the sentinel lymph node (SLN) in clinically node negative breast cancer patients detects metastatic disease and enables axillary lymph node dissection to be performed in the same operative setting. Internationally, the false negative rate (FNR) for SLN biopsy ranges from 5.5% to 43%. The size of SLN metastasis has been identified as a key factor affecting FNR. We review our institutional experience on the accuracy of intraoperative SLN biopsy.

METHODS

Data were collected retrospectively from patients undergoing SLN biopsy performed at Singapore General Hospital. The SLN was identified using blue dye, radioisotope or both. Frozen section was performed intraoperatively. When SLN was positive for metastasis on frozen section, completion axillary clearance was performed. False negative cases were defined as patients in whom a negative frozen section result was obtained, whose final permanent paraffin section was positive. We determined the FNR of SLN frozen section and evaluated the factors associated with it.

RESULTS

A total of 2202 SLN biopsies were performed between January 2005 and June 2012. There were 89 false negative cases, of which there were 23 (25.8%) cases of isolated tumour cells (ITCs), 49 (55.1%) cases of micrometastasis, and 17 (19.1%) cases of macrometastasis. The overall FNR was 13.5%. FNR was 79.3% in ITCs, 59.8% in micrometastasis, and 3.1% in macrometastatic disease. Non-ductal histological subtype, absence of lymphovascular invasion and the size of SLN metastasis were identified as significant independent factors associated with a higher FNR.

CONCLUSIONS

FNRin our institution is acceptable when compared to other large centres. Failure to detect metastasis in frozen section in more than half of our patients was due to ITCs and micrometastasis.

Assessment of breast pathologies using nonlinear microscopy

Rapid intraoperative assessment of breast excision specimens is clinically important because up to 40% of patients undergoing breast-conserving cancer surgery require reexcision for positive or close margins. We demonstrate nonlinear microscopy (NLM) for the assessment of benign and malignant breast pathologies in fresh surgical specimens. A total of 179 specimens from 50 patients was imaged with NLM using rapid extrinsic nuclear staining with acridine orange and intrinsic second harmonic contrast generation from collagen. Imaging was performed on fresh, intact specimens without the need for fixation, embedding, and sectioning required for conventional histopathology. A visualization method to aid pathological interpretation is presented that maps NLM contrast from two-photon fluorescence and second harmonic signals to features closely resembling histopathology using hematoxylin and eosin staining. Mosaicking is used to overcome trade-offs between resolution and field of view, enabling imaging of subcellular features over square-centimeter specimens. After NLM examination, specimens were processed for standard paraffin-embedded histology using a protocol that coregistered histological sections to NLM images for paired assessment. Blinded NLM reading by three pathologists achieved 95.4% sensitivity and 93.3% specificity, compared with paraffin-embedded histology, for identifying invasive cancer and ductal carcinoma in situ versus benign breast tissue. Interobserver agreement was κ = 0.88 for NLM and κ = 0.89 for histology. These results show that NLM achieves high diagnostic accuracy, can be rapidly performed on unfixed specimens, and is a promising method for intraoperative margin assessment.

Treatment of irradiated expanders: protective lipofilling allows immediate prosthetic breast reconstruction in the setting of postoperative radiotherapy

BACKGROUND

Immediate two-stage prosthetic breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) currently is hardly achieved with the fast-track expander exchange proposed by Cordeiro and colleagues or the delayed-immediate breast reconstruction proposed by Kronowitz and Robb. Each of these techniques has important drawbacks and complications. To overcome these problems, the authors in 2011 described lipofilling on irradiated expanders in patients undergoing unplanned PMRT (Cagliari University Hospital [CUH] protocol) for early breast cancers with specific risk factors. The authors report their experience after expanding the use of such a protocol for any immediate expander/implant reconstruction in a patient undergoing PMRT.

METHODS

The timing for advanced breast cancer involves immediate reconstruction with a tissue expander, complete tissue expansion, radiotherapy (RT) after neoadjuvant chemotherapy starting 2-3 months after mastectomy, one or two fresh fat-grafting sessions at least 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. The timing for early breast cancers with specific risk factors involves immediate reconstruction with a tissue expander, complete tissue expansion during postoperative chemotherapy, RT 6 months after mastectomy, one or two fat-grafting sessions 6 weeks after RT, and an expander-implant exchange with anterior capsulectomy at least 3 months after the completion of fat grafting. From 2008 to 2012, 16 patients undergoing total mastectomy and immediate expander-implant breast reconstruction with subsequent PMRT were treated according to the CUH protocol.

RESULTS

The results have been extremely encouraging, with rates of ulceration and implant exposure in the radiotreated area dropping to 0 %. These results were retrospectively compared with those for a control group of 16 patients who underwent immediate implantation of an expander. In this latter group, the extrusion rate of the implant in the end was 31.25 %, and this was statistically significant (p < 0.03). The shape and symmetry also were significantly better in the lipofilled patients.

CONCLUSION

Protective lipofilling on irradiated expanders appears to be a valid technique for avoiding ulceration and implant exposure after PMRT while allowing a complete expansion.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of the benefit of routine intraoperative frozen section analysis of sentinel lymph nodes in breast cancer

Aims. Intraoperative analysis of the sentinel lymph node (SLN) by frozen section (FS) allows for immediate axillary lymph node dissection (ALND) in case of metastatic disease in patients with breast cancer. The aim of this study is to evaluate the benefit of intraoperative FS, with regard to false negative rate (FNR) and influence on operation time. Materials and Methods. Intraoperative analysis of the SLN by FS was performed on 628 patients between January 2005 and October 2009. Patients were retrospectively studied. Results. FS accurately predicted axillary status in 525 patients (83.6%). There were 78 true positive findings (12.4%), of which there are 66 macrometastases (84.6%), 2 false positive findings (0.3%), and 101 false negative findings (16.1%), of which there are 65 micrometastases and isolated tumour cells (64.4%) resulting in an FNR of 56.4%. Additional operation time of a secondary ALND after wide local excision and SLNB is 17 minutes, in case of ablative surgery 35 minutes. The SLN was negative in 449 patients (71.5%), making their scheduled operation time unnecessary. Conclusions. FS was associated with a high false negative rate (FNR) in our population, and the use of telepathology caused an increase in this rate. Only 12.4% of the patients benefited from intraoperative FS, as secondary ALND could be avoided, so FS may be indicated for a selected group of patients.

[Diagnostic validity of the intraoperative analysis in frozen section of the sentinel lymph node in the surgical management of breast cancer]

OBJECTIVE

The method for intraoperative sentinel lymph node (SLN) evaluation has still not been established in breast cancer staging. This study has evaluated the diagnostic validity and impact of intraoperative analysis using the frozen section (FS) of SLN.

MATERIAL AND METHODS

We performed a descriptive study of the diagnostic validity of the FS of the SLN in patients with breast cancer and selective sentinel node biopsy (SSNB) from October-2006 to October-2012. The diagnostic validity indexes were evaluated using sensitivity, specificity, positive and negative predictive values and global value. Gold standard was considered as the final histopathological results of the biopsies.

RESULTS

A total of 370 patients were studied. Sensitivity and specificity for detection of metastasis by FS in the SLN were 67% and 100%, respectively. Global diagnostic validity was 95%. There was a correlation between detection of metastasis and tumor size (p<0.05). Twelve of the 15 patients with SLN micro-metastases underwent axillary lymph node dissection (ALND). Metastatic lymph nodes were not found in any of them.

CONCLUSIONS

Intraoperative FS examination of the SLN is a useful and reliable predictor of axillary lymph node staging in patients with initial stages of breast cancer. FS reduces the need for second interventions, at least for most patients who have breast cancer with identifiable positive SLN and unequivocal evidence of positive lymph node disease.

Novel diagnostic procedure for determining metastasis to sentinel lymph nodes in breast cancer using a semi-dry dot-blot method

We developed an easy, quick and cost-effective detection method for lymph node metastasis called the semi-dry dot-blot (SDB) method, which visualizes the presence of cancer cells with washing of sectioned lymph nodes by anti-pancytokeratin antibody, modifying dot-blot technology. We evaluated the validity and efficacy of the SDB method for the diagnosis of lymph node metastasis in a clinical setting (Trial 1). To evaluate the validity of the SDB method in clinical specimens, 180 dissected lymph nodes from 29 cases, including breast, gastric and colorectal cancer, were examined. Each lymph node was sliced at the maximum diameter and the sensitivity, specificity and accuracy of the SDB method were determined and compared with the final pathology report. Metastasis was detected in 32 lymph nodes (17.8%), and the sensitivity, specificity and accuracy of the SDB method were 100, 98.0 and 98.3%, respectively (Trial 2). To evaluate the efficacy of the SDB method in sentinel lymph node (SLN) biopsy, 174 SLNs from 100 cases of clinically node-negative breast cancer were analyzed. Each SLN was longitudinally sliced at 2-mm intervals and the sensitivity, specificity, accuracy and time required for the SDB method were determined and compared with the intraoperative pathology report. Metastasis was detected in 15 SLNs (8.6%), and the sensitivity, specificity, accuracy and mean required time of the SDB method were 93.3, 96.9, 96.6 and 43.3 min, respectively. The SDB method is a novel and reliable modality for the intraoperative diagnosis of SLN metastasis.

Multiple Step-section Frozen Section sentinel lymph node biopsy--a review of 717 patients

Sentinel Lymph Node Biopsy (SLNB) is the standard of care for axillary staging in breast cancer. Multiple Step-section Frozen Section (MSFS) analysis is used in our institution for SLNB. This is performed intra-operatively by freezing sentinel lymph nodes to obtain multiple step-sections which are examined histologically for evidence of metastases. Patients whose sentinel lymph nodes contained macrometastases proceeded to an axillary node clearance during the same operation. 717 patients over a two and a half year period had MSFS analysis. With regards to macrometastases, MSFS analysis had a sensitivity of 93.8%, a specificity of 99.3%, a positive-predictive value of 97.4% and a negative-predictive value of 98.2%. MSFS analysis of sentinel lymph nodes is a safe and accurate procedure. It is a relatively cost-effective alternative to molecular technologies relying on DNA amplification and more accurate than standard frozen section or touch-prep cytology.

Intraoperative frozen section analysis of sentinel lymph nodes in breast carcinoma patients in a tertiary hospital in Pakistan

Intraoperative evaluation of sentinel lymph nodes has become routine in many units that manage early breast carcinoma. The procedure is associated with minimal morbidity and can be cost effective, avoiding re operation and reducing hospital stay as an axillary clearance can be performed under the same anesthetic after a positive intraoperative diagnosis without awaiting conventional paraffin histology. In negative cases extensive axillary lymph node dissection and its associated side effects can be avoided altogether. With careful patient selection, the expertise of surgeons and pathologists can increase the sensitivity and specificity of the technique with a reduction in false negatives. A number of international studies have established the usefulness of intraoperative sentinel lymph node evaluation. However, no local study has assessed the accuracy of frozen section in evaluating sentinel lymph node biopsy. The purpose of our study was to compare the two techniques (frozen section versus conventional paraffin histology) of the sentinel lymph node examination and to present our local data highlighting its usefulness and pitfalls, comparing the results with those in published studies. From the results obtained, we strongly recommend intraoperative assessment of the sentinel lymph nodes in breast carcinoma patients; frozen section microscopy can be a reliable and accurate technique in the hands of an experienced histopathologist.

Achieving breast cancer surgery in a single setting with intraoperative frozen section analysis of the sentinel lymph node

BACKGROUND

Current guidelines recommend full axillary lymph node dissection (ALND) whenever the SLN is positive for metastases. In our institute, we aim to complete surgery in a single setting and base the decision for ALND on the intraoperative FS analysis of the SLN. In this study, we evaluate the efficacy this practice in terms of the accuracy of FS analysis, patient recall rate, and additional time required for FS analysis.

MATERIALS AND METHODS

Retrospective review was performed of 586 patients who underwent SLN biopsy at our institution from January 1, 2006 to December 31, 2010. Intraoperative FS analysis was routinely performed in all cases with a preoperative diagnosis of invasive breast cancer and in selected cases of ductal carcinoma in situ according to surgeon preference.

RESULTS

The SLN was positive for metastases in 123 (22.7%) patients; this was identified on FS analysis in 107 patients. FS analysis had a sensitivity of 87.0% and specificity of 100% and resulted in a patient recall rate of 3%. Micrometastasis accounted for most of the false negative FS results. These deposits were mostly detected only on deeper sectioning of the permanent sections of the SLN. An invasive lobular histology and lymphovascular invasion were found to be independent predictors of a false negative FS on multivariate analysis (P < .01). Intraoperative FS did not significantly prolong operating times.

CONCLUSION

Intraoperative FS analysis is an accurate and efficient means of rapid SLN assessment and allows ALND to be completed in a single setting.

Reliability of frozen section in breast sentinel lymph node examination

OBJECTIVES

Sentinel lymph node (SLN) examination in breast carcinoma is crucial to spare patients unnecessary lymph node (LN) dissection. The specificity and accuracy of SLN examination by frozen section has been variable in many studies. This study aims to describe our experience in frozen section (FS) analysis of SLN.

METHODS

We have retrospectively analyzed data from 449 axillary SLN subjected to FS examination from 440 patients with breast cancer. All patients had free axillary LN clinically.

RESULTS

Out of 449 cases, no false positive cases were found on FS (specificity of 100 %). Twenty-six cases were false negative (6 interpretation-related reasons and 20 technical-related reasons). The overall sensitivity was 84 % with a total accuracy rate of 93 % and interpretation sensitivity of 96 %. Three cases were deferred. Twenty-two of the false negative cases were micrometastases, whereas 4 were macrometastases. The interpretation-related false negative cases were not related to the subtype of carcinoma (ductal vs. lobular). However, they were all of low nuclear grade.

CONCLUSION

These findings are similar to most published data. FS is a reliable method for evaluating SLN. The most common cause of false negative diagnosis is sampling error. More attention should be paid to low-grade tumors. Moreover, in FS analysis, we recommend to totally submit SLNs that are less than 5 mm in diameter, bisecting them if possible, and to serially section SLNs that are at least 5 mm at 2-mm intervals.

Is intraoperative imprint cytology evaluation still feasible for the evaluation of sentinel lymph nodes for lobular carcinoma of the breast?

BACKGROUND

The evaluation of sentinel lymph nodes (SLNs) from a patient with lobular breast cancer is challenging. Metastatic lobular cancer is difficult to identify in SLNs because of its low-grade cytomorphology and its tendency to resemble lymphocytes. Intraoperative imprint cytology (IIC) is a rapid, reliable method for evaluating SLNs intraoperatively. We sought to reexamine our experience with this technique in the identification of invasive lobular breast cancer SLN metastases.

METHODS

A retrospective review of a prospectively maintained database of IIC results of 1010 SLN mapping procedures for breast cancer was performed. From this cohort we reviewed SLN cases of lobular cancer. The SLNs were evaluated intraoperatively by bisecting the SLN. Imprints were made of each cut surface and stained with hematoxylin and eosin (H&E) and Diff-Quik. Permanent sections were evaluated with up to 4 H&E-stained levels and cytokeratin immunohistochemistry. IIC results were compared with final pathologic results.

RESULTS

A total of 67 cases of pure invasive lobular cancer were identified. The sensitivity was 71%, specificity was 100%, and accuracy was 92%. No statistically significant differences in sensitivity, specificity, or accuracy were identified between the intraoperative detection of lobular carcinoma vs ductal carcinoma. The specificity has remained the same since 2004. However the accuracy (82% vs 92%; P = .09) and sensitivity (52% vs 71%; P = .02) has improved since 2004.

CONCLUSIONS

As we have previously shown, the sensitivity and specificity of IIC in evaluating lobular carcinoma is feasible and accurate. IIC continues to be a viable alternative to frozen section for intraoperative evaluation.

Breast reconstruction and adjuvant therapies

Recent developments in the management of breast cancer have increased the complexity of planning for immediate breast reconstruction. Two recent trials have demonstrated superior locoregional control, disease-free survival, and overall survival in node-positive breast cancer patients with the addition of postmastectomy radiation therapy (XRT) to mastectomy and chemotherapy. On the basis of these results, the use of postmastectomy XRT in patients with early-stage breast cancer is increasing. Unfortunately, it is difficult to predict the presence or extent of axillary lymph node involvement-a major determinant of the need for postmastectomy XRT-before mastectomy. There are two potential problems with performing an immediate breast reconstruction in a patient who will require postmastectomy XRT. First, postmastectomy XRT can adversely affect the aesthetic outcome of an immediate breast reconstruction. Second, an immediate breast reconstruction can interfere with the delivery of postmastectomy XRT. Chemotherapy before or after reconstruction does not significantly increase the occurrence of wound-healing problems and breast reconstruction does not appear to delay the initiation or resumption of chemotherapy. The increasing use of postmastectomy XRT and chemotherapy in patients with early-stage breast cancer necessitates increased communication between the medical oncologist, radiation oncologist, breast surgeon, and plastic surgeon during treatment planning for these patients.

Accuracy of Intraoperative Macroscopic Diagnosis of Sentinel Node Metastases in Breast Cancer: Is Accurate Prediction Possible?

Background

Accurate intraoperative diagnosis of sentinel lymph node (SLN) metastases enables the selection of patients who require axillary lymph node dissection, thus avoiding an additional operation. In this study we investigated the accuracy of intraoperative macroscopic diagnosis of SLN metastases in patients with breast cancer.

Methods

SLNs from 276 breast cancer patients with clinically negative nodes were analyzed by macroscopic examination. The results of intraoperative macroscopic diagnosis were compared with those of frozen section analysis.

Results

The sensitivity, specificity, overall accuracy, and false negative rate of SLN biopsy in the assessment of node status were 82.1%, 100%, 96.4%, and 17.9%, respectively, for frozen section analysis, and 57.1%, 95.5%, 87.7%, and 42.9%, respectively, for macroscopic evaluation. Even in patients with node metastasis >7 mm, the false negative rate of macroscopic evaluation was 11.1%.

Conclusions

Our results suggest that macroscopic diagnosis is less effective in predicting lymph node status in breast cancer than frozen section analysis. These findings imply that intraoperative macroscopic evaluation of sentinel nodes is never predictive of the final pathology. Free full text available at www.tumorionline.it

Impact of the sentinel node frozen section result on the probability of additional nodal metastases as predicted by the MSKCC nomogram in breast cancer

OBJECTIVE

Sentinel lymph node frozen section is used to obviate the need for a second operation in breast cancer patients with involved nodes. However, the overall sensitivity, specificity and accuracy of sentinel lymph node frozen section are debated, and the impact of sentinel lymph node frozen section positivity on the risk of additional nodal metastases is not known and was the focus of this investigation.

METHODS

We used our hospital record system to identify 176 sentinel lymph node biopsies done out of 354 cases of Stage T1-3N0 breast cancers managed from 2005 to 2007 and evaluated the sentinel lymph node frozen section results against the predictions of additional nodal metastases based on the Memorial Sloan-Kettering Breast Cancer Nomogram which is a validated tool for this purpose.

RESULTS

Sentinel lymph node metastases size was an independent predictor of sentinel lymph node frozen section sensitivity and those with macrometastases had 15 times the odds (odds ratio, 15.4; 95% confidence interval, 3.4-69.1) of having a true-positive frozen section when compared with those with micrometastases. The breast cancer nomogram predicted that the latter patients have a very low probability of additional nodal metastases with a median probability at 10% (inter-quartile range, 7-14%).

CONCLUSIONS

A negative sentinel lymph node frozen section is also associated with a low probability of additional nodal metastases. Additional prognostic factors in the breast cancer nomogram are of little clinical impact because the most predictive factor in the nomogram is the method of detection.

Intraoperative assessment of sentinel lymph nodes in breast cancer

Background

Sentinel lymph node biopsy (SLNB) reduces the morbidity of axillary clearance and is the standard of care for patients with clinically node-negative breast cancer. The ability to analyse the sentinel node during surgery enables a decision to be made whether to proceed to full axillary clearance during primary surgery, thus avoiding a second procedure in node-positive patients.

Methods

Current evidence for intraoperative sentinel node analysis following SLNB in breast cancer was reviewed and evaluated, based on articles obtained from a MEDLINE search using the terms ‘sentinel node’, ‘intra-operative’ and ‘breast cancer’.

Results and conclusion

Current methods for evaluating the sentinel node during surgery include cytological and histological techniques. Newer quantitative molecular assays have been the subject of much recent clinical research. Pathological techniques of intraoperative SLNB analysis such as touch imprint cytology and frozen section have a high specificity, but a lower and more variably reported sensitivity. Molecular techniques are potentially able to sample a greater proportion of the sentinel node, and could have higher sensitivity.