Frozen section evaluation of breast carcinoma sentinel lymph nodes: a retrospective review of 1,940 cases

Update on Sentinel Lymph Node Methods and Pathology in Breast Cancer

Breast cancer stands out as the most commonly diagnosed cancer among women globally. Precise lymph node staging holds critical significance for both predicting outcomes in early-stage disease and formulating effective treatment strategies to control regional disease progression in breast cancer patients. No imaging technique possesses sufficient accuracy to identify lymph node metastases in the early stages (I or II) of primary breast cancer. However, the sentinel node procedure emerges as a valuable approach for identifying metastatic axillary nodes. The sentinel lymph node is the hypothetical first lymph node or group of nodes draining a cancer. In case of established cancerous dissemination, it is postulated that the sentinel lymph nodes are the target organs primarily reached by metastasizing cancer cells from the tumor. The utilization of the sentinel node technique has brought about changes in the assessment of lymph nodes. It involves evaluating the sentinel node during surgery, enabling prompt lymph node dissection when the sentinel node procedure is positive. Additionally, histological ultra-stratification is employed to uncover occult metastases. This review aims to provide an update of this valuable technique, with focus on the practical aspects of the procedure and the different histological protocols of sentinel node evaluation in breast cancer.

Accuracy of Intraoperative Frozen Section Analysis of Lymph Nodes in Women Undergoing Axillary Sampling for Treatment of Breast Cancer: Single Institution Audit

BACKGROUND

Axillary lymph node (LN) positivity is an important prognostic factor in breast cancer. Almost 30% clinically node negative (cN0) early breast cancers have positive nodes on pathology, wherein an axillary dissection is done as a second stage surgery. Intra operative frozen section (FS) potentially avoids redo surgery.

MATERIALS AND METHODS

We performed a retrospective audit for the false negative rate of intraoperative FS, from 2014 to 2018. All cN0 women undergoing upfront surgery, who underwent low axillary sampling (LAS) with FS were included.

RESULTS

Of 22,854 breast cancer cases, 2230 underwent LAS, of which 877 were node positive. Intraoperative FS was negative in 1423/2230 (63.81%) cases, of which 71/1423 (4.98%) were false negative, and came positive on final histopathology report (HPR). These 71 women had a median of 5 nodes (mean 4.85) dissected on FS (range 1-12) with a median 1 (mean 1.3) node positive (range 1-6) on HPR. The sensitivity of FS was 91.89% (95% CI, 89.89-93.62), with a negative predictive value of 95.01% (95% CI, 93.84-95.97), accuracy of 96.73% (95% CI, 95.90-97.43) and false negative rate 4.98%. On logistic regression analysis, micrometastasis (Odds ratio (OR) 7.76, 95% CI, 3.49-17.25, P < .001) lobular histology (OR 2.50, 95% CI, 1.007-6.223, P = .04) and nodes dissected (OR 1.18, 95% CI, 1.07-1.30, P = .001) were associated with higher false negative FS, and extra nodal extension (OR 0.32, 95% CI, 0.18-0.57, P ≤ .001) with lower false negative FS.

CONCLUSION

The high concordance between intraoperative FS and definitive histology, suggests it's routine use for Sentinel lymph node/LAS LN can help avoid a second surgery.

The extent of agreement between frozen and paraffin block data from axillary samples in patients with early-stage breast cancer

INTRODUCTION

Patients with early-stage breast cancer currently undergo sentinel lymph node dissection to evaluate the axillary region. Frozen tissue blocks are evaluated intra operatively and paraffin-embedded samples are studied postoperatively. We explored whether sentinel lymph node dissection adequately reflected axillary involvement (as revealed by the paraffin blocks) in patients with early-stage breast cancer; we sought to avoid axillary dissection.

METHODS

The agreement/non-agreement rates between the results of axillary ultrasonography and biopsy, sentinel lymph node and axillary dissections, and frozen and paraffin block results, were retrospectively analyzed for 200 patients with early-stage breast cancer. The positive predictive values and accuracies were recorded in those who were positive on both ultrasonography and biopsy. The negative predictive values were calculated for doubly negative cases.

RESULTS

The frozen and paraffin block results disagreed in 19 (9.5 %) cases and agreed in 181 (90.5 %). The frozen block and dissection results differed in five of 38 patients who underwent axillary dissection (AD) (one patient did not undergo AD); the results were in agreement in 32. Of the 19 block-disagreement cases, 16 were in the non-neoadjuvant chemotherapy (NAC) group and three in the NAC treatment group. Clinically, the negative predictive values of the frozen and paraffin block data were 80 % in patients lacking axillary involvement.

CONCLUSION

Paraffin block evaluations only (thus, without frozen block examinations) of early-stage breast cancer lymph nodes seem to be sufficient to guide treatment. Also, a thorough clinical examination (with ultrasonography and axillary biopsy) reduces the dissection rate and the associated functional impairments.

A Quantitative and Qualitative Assessment of Frozen Section Diagnosis Accuracy and Deferral Rate Across Organ Systems

OBJECTIVES

Monitoring of frozen section diagnostic performance provides an important quality improvement measure.

METHODS

Surgical specimens involving a frozen section diagnosis over a 3-year period were retrospectively reviewed. Glass slides were reviewed on cases with discordance. Discordance and deferral rates were calculated.

RESULTS

Of 3,675 frozen section diagnoses included, 96 (2.7%) were discordant with the final diagnosis. Additionally, 114 frozen section diagnoses (3.1%) were deferred. The organ-specific discordance rates were lowest in breast and genitourinary specimens and highest for pancreas, lymph node, and gynecologic specimens. Deferral rates were highest in musculoskeletal, breast, and hepatobiliary cases and lowest in thyroid, parathyroid, and neuropathology cases. Discordance was explained by block-sampling error (45%), specimen-sampling error (27%), or interpretation error (27%). Discordant frozen section diagnoses from gynecologic specimens were responsible for 81% of specimen-sampling errors; frozen section diagnoses of lymph nodes, head and neck, and pancreas were responsible for 54% of interpretation errors; 51% of block-sampling errors involved lymph node evaluation for metastatic carcinoma.

CONCLUSIONS

Careful gross evaluation and microscopic examination of multiple levels should minimize specimen-sampling error and block-sampling error, respectively. Periodic review of accuracy and deferral rates may help reduce errors and improve the overall performance of this essential procedure.

Is Routine Intraoperative Frozen Section Analysis of Sentinel Lymph Nodes Necessary in Every Early-Stage Breast Cancer?

Purpose

Clinical application of the ACOSOG Z0011 trial results allows clinically node-negative breast cancer patients who meet criteria to avoid axillary dissection even when 1–2 sentinel lymph nodes (SLNs) are positive for metastatic disease. Intraoperative frozen section (iFS) analyses of SLNs were thought to reduce re-operation rates despite variable reported sensitivity and possibility of a false negative result. This study evaluated the rate of re-operations prevented by SLN iFS in a tertiary care hospital in Bangkok, Thailand, over a 6-year time-frame.

Patients and Methods

From April 2016 to April 2022, 1284 sentinel lymph node biopsy (SLNB) procedures were performed. Of these, 214 cases were breast-conserving surgery in accordance with the ACOSOG criteria with concomitant usage of iFS. Clinicopathological features of these cases were collected and analyzed. Re-operation rates prevented by the additional intervention were reported.

Results

Only five additional operations were prevented with the usage of 214 iFS. The discordance rate between frozen and permanent sections in terms of presence of metastatic disease and number of total lymph nodes was around 15%. Tumor staging, node staging, Nottingham histologic grading and lymphovascular invasion are significant predictors of SLN metastasis.

Conclusion

iFS results in a very low prevention rate for follow-up ALND in patients with preoperative clinically negative axillary nodes and is associated with a non-negligible discordance rate with permanent sections. Our study suggests iFS may be avoided in most cases of early-stage clinically and radiographically node-negative breast cancer patients. Doing so may reduce surgical costs and total operative time without a significant impact on the overall quality of treatment and standard of care.

Update on sentinel node pathology in breast cancer

Pathologic examination of the sentinel lymph nodes (SLNs) in patients with breast cancer has been impacted by the publication of practicing changing trials over the last decade. With evidence from the ACOSOG Z0011 trial to suggest that there is no significant benefit to axillary lymph node dissection (ALND) in early-stage breast cancer patients with up to 2 positive SLNs, the rate of ALND, and in turn, intraoperative evaluation of SLNs has significantly decreased. It is of limited clinical significance to pursue multiple levels and cytokeratin immunohistochemistry to detect occult small metastases, such as isolated tumor cells and micrometastases, in this setting. Patients treated with neoadjuvant therapy, who represent a population with more extensive disease and aggressive tumor biology, were not included in Z0011 and similar trials, and thus, the evidence cannot be extrapolated to them. Recent trials have supported the safety and accuracy of sentinel lymph node biopsy (SLNB) in these patients when clinically node negative at the time of surgery. ALND remains the standard of care for any amount of residual disease in the SLNs and intraoperative evaluation of SLNs is still of value for real time surgical decision making. Given the potential prognostic significance of residual small metastases in treated lymph nodes, as well as the decreased false negative rate with the use of cytokeratin immunohistochemistry (IHC), it may be reasonable to maintain a low threshold for the use of cytokeratin IHC in post-neoadjuvant cases. Further recommendations for patients treated with neoadjuvant therapy await outcomes data from ongoing clinical trials. This review will provide an evidence-based discussion of best practices in SLN evaluation.

Evolution of Frozen Section in Carcinoma Breast: Systematic Review

Background. The frozen section (FS) has been a good technique in surgical management of breast lesions since many years. But complete agreement and cooperation have not been achieved everywhere among surgeons and pathologists especially in the developing countries. FS undergoes continuous criticism due to various shortcomings but continued to be evaluated especially in developing countries. Objectives. This review was conducted to synthesize information on the use of frozen section in carcinoma breast. Data Sources. The MEDLINE database for frozen section since its origin and its implication in recent breast surgery techniques was studied. Study Eligibility Criteria. Sixty-five articles were reviewed with complete analysis on FS in both benign and malignant breast lesions. Study Appraisal and Synthesis Methods. The analysis of frozen section was done as a diagnostic tool in breast lesions, margin status in breast conservative surgery in carcinoma breast, and sentinel lymph node and use of immunohistochemistry for sentinel lymph node FS. Results. It was analysed that the FS gives accurate results in margin status analysis, decreasing rerecurrence. Conclusion. The accuracy of FSA, low recurrence rate, avoidance of reoperation, and good cosmesis are the key points of its use in breast conservative surgery. Its use in sentinel lymph node biopsy (SLNB) is equivocal. However, application of immunohistochemistry on frozen section of SLNB is an evolving trend in today’s era.

Axillary Lymph Node Dissection Can Be Omitted in Breast Cancer Patients With Mastectomy and False-Negative Frozen Section in Sentinel Lymph Node Biopsy

Background

The IBCSG 23-01 and AMAROS trials both reported that axillary lymph node dissection (ALND) did not change survival rates in breast cancer patients with positive nodes detected by sentinel lymph node biopsy (SLNB). The aim of this study was to determine whether breast cancer patients with mastectomy and false-negative frozen section (FS) in SLNB could forgo ALND.

Materials and Methods

This was a retrospective study of cN0 patients diagnosed with primary invasive breast cancer treated by mastectomy and SLNB at our institute between January 2010 and December 2014. Patients with false-negative FS in SLNB were separated by the following management of axillary lymph node dissection in the non-ALND group (nonprocess or axillary radiation only) and ALND group (with or without radiation).

Results

A total of 212 patients were included, 86 and 126 patients in the non-ALND and ALND groups, respectively. The positive rate of non-sentinel lymph nodes (SLNs) was 15.87% (20/126) in the ALND group. In multivariate analysis, we found that patients with larger tumor size (>2 cm) (OR, 1.989; p = 0.030) and multifocal lesions (OR, 3.542; p = 0.029) tended to receive ALND. The positivity of non-SLNs in the ALND group was associated with SLN macrometastasis (OR, 3.551; p = 0.043) and lymphovascular invasion (OR, 6.158; p = 0.003). Also, removing more SLNs (≥3) was related to negativity in non-SLNs (OR, 0.255; p = 0.016). After a median follow-up of 59.43 months, RFS and OS of the two groups were similar (p = 0.994 and 0.441). In subgroup analysis, we found that 97 patients who met the inclusive criteria of the IBCSG 23-01 trial had similar RFS and OS between the non-ALND and ALND groups (p = 0.856 and 0.298). The positive rate of non-SLNs was 9.62% (5/52). Also, in 174 patients who met the criteria of the AMAROS trial, RFS and OS in the non-ALND and ALND groups were similar (p = 0.930 and 0.616). The positive rate of non-SLNs was 18.27% (19/104).

Conclusion

ALND can be carefully omitted in selected breast cancer patients with mastectomy and false-negative FS in SLNB. SLNB is relatively sufficient in the IBCSG 23-01-eligible patients, and axillary radiation was an effective option in the AMAROS-eligible patients.

Diagnostic Value of Intraoperative Frozen Section in Breast-Conserving Surgery: A Systematic Review and Meta-analysis

Context: According to previous studies, using the frozen section procedure during breast surgery reduces the rate of error and the need for re-surgery. We aimed at performing a comprehensive systematic review and meta-analysis to provide reliable evidence on the diagnostic value of frozen section procedures in breast-conserving surgery (BCS). Data Sources: A thorough search was performed in PubMed, Embase, Cochrane Library, and Web of Science databases for human diagnostic studies that used the frozen section in BCS. Meta-analyses were done to find the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Study Selection: Human diagnostic studies used the frozen section in breast-conserving surgery and studies that reported the sensitivity and specificity of the frozen section in BCS or contained data that could be calculated the desired parameters were selected for this meta-analysis. Data Extraction: Assessment of studies quality was done and data was extracted from included papers. Then, the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess the quality of included papers. Results: Thirty-five papers were entered into our study. The meta-analysis indicated the high sensitivity (83.47, 95%CI 79.61 - 87.32) and specificity (99.29, 95%CI 98.89 - 99.68) for the frozen section in BCS, which resulted in an accuracy of 93.77 (95%CI 92.45 - 95.10). We also found a significant PPV (93.26, 95%CI 91.25 - 95.27), NPV (92.17, 95%CI 90.22 - 94.11), PLR (7.99, 95%CI 6.01 - 9.96), and NLR (0.18, 95%CI 0.14 - 0.23). Conclusions: The findings showed that intraoperative frozen section analysis has high sensitivity and specificity for evaluating lumpectomy margins in patients with early-stage breast cancer and significantly reduces the need for re-operation. Accordingly, re-operation costs are not imposed on the patient and reduce the anxiety of the patients.

Intra-operative assessment of sentinel lymph nodes for breast cancer surgery: An update

Lymph node (LN) involvement is the strongest prognostic factor in operable breast cancer (BC). Therefore, accurate assessment of LN status is essential for management of BC patients. The introduction of sentinel LN approach reduced the need for extensive axillary surgery to achieve accurate staging. However, positive sentinel LN as determined on postoperative histological examination often leads to a second axillary operation to ensure an accurate staging and that positive non-sentinel LNs are removed. Although preoperative assessment of LN has improved significantly, its accuracy remains insufficient to avoid further axillary surgery and is not sufficient to predict the status of the LN. Therefore, intraoperative evaluation of the sentinel LN to determine the need for completing lymph node dissection in case of metastasis can provide an important approach to guide BC management decision making. This article reviews the techniques available and under development for intraoperative detection of sentinel LN metastasis in BC surgery. The key features of each technique are described in detail, emphasising the benefits offered by label-free optical techniques: minimal sample preparation, high spatial resolution, and immediate on-site implementation. Optical techniques have the potential to provide a cost-effective and accurate intraoperative platform for the assessment of SLN within the operating theatre.

Real-time diagnosis of sentinel lymph nodes involved to breast cancer based on pH sensing through lipid synthesis of those cells

Lipid synthesis is the recently found metabolism of cancer cells after their metastasis to lymph nodes (LNs). Carbonic acid is the main byproduct of the lipid metabolism in such cells which resulted in acidification of LN ambient. Hence, calibrated pH sensing could be a diagnostic method to find involved LNs. Here, we designed a simple pH sensing method by a syringe containing sterile PBS and embedded by litmus paper to intraoperatively check the pH of LN fluid. Injected phosphate buffer saline (PBS) would homogenize the LN fluid and litmus needle would detect the pH of the LN. We presented an experimental pathological calibration for the pH values in correlation with cancerous states of the LNs. This system named metabolism based metastatic lymph diagnoser (MMLD) could be a real-time noninvasive tool for precise and fast diagnosis of involved LNs.

Locoregional Management of the Axilla in Mastectomy Patients with One or Two Positive Sentinel Nodes: The Role of Intraoperative Pathology

INTRODUCTION

Controversy exists regarding optimal management of the axilla in clinically node-negative (cN0) mastectomy patients with one or two positive sentinel lymph nodes (+SLNs). We evaluated the influence of frozen-section pathology on axillary management and recurrence.

PATIENTS AND METHODS

We studied cN0 breast cancer patients treated from 2008 to 2018 with mastectomy and SLN surgery with one or two +SLNs. Patients with one or two +SLNs identified on frozen-section intraoperatively (FS+SLN) were compared to those with one or two +SLNs not detected by frozen section (FS-SLN). Recurrence rates were estimated using the Kaplan-Meier method.

RESULTS

Of 2295 cN0 mastectomy patients, 338 patients had one or two +SLNs: 108 (32%) FS-SLN and 230 (68%) FS+SLN. In the FS+SLN cases, completion axillary lymph node dissection (cALND) was more frequent (97% vs. 39%; P < .001), and median SLN metastasis size (5 vs. 1.3 mm; P < .001) and likelihood of positive non-SLNs (31% vs. 14%; P = .02) were greater compared with FS-SLN cases. Across all 338 patients, 40% had SLN surgery alone, and 47% of cALND patients received post-mastectomy radiation therapy (PMRT). At a median follow-up of 61 months, no axillary recurrences were observed among FS-SLN patients. Among FS+SLN patients, 97% proceeded to cALND but 49% avoided PMRT; three regional nodal recurrences were observed (all in patients treated with cALND, of whom two received PMRT).

CONCLUSION

Mastectomy patients with one or two FS+SLNs have a higher nodal disease burden than FS-SLN patients. The majority of FS+SLN patients underwent cALND, and 51% received PMRT with very low 5-year regional nodal recurrence rates. A substantial proportion of FS-SLN patients successfully avoided both cALND and PMRT. Frozen-section pathology analysis can guide de-escalation of axillary management.

Endosalpingiosis Is Negative for GATA3

CONTEXT.—

Endosalpingiosis is a benign Müllerian inclusion that can mimic metastatic low-grade mammary carcinoma, particularly when encountered in axillary lymph nodes excised for breast cancer staging. Immunohistochemistry can be useful in histologically ambiguous cases, and a targeted immunopanel should include a marker of gynecologic tract origin and a marker of mammary origin. GATA3 is a sensitive immunomarker for breast carcinoma, but the immunoreactivity of GATA3 in endosalpingiosis has not been systematically evaluated.

OBJECTIVE.—

To evaluate whether GATA3 immunohistochemistry could be used to differentiate endosalpingiosis from metastatic mammary carcinoma.

DESIGN.—

Whole slide sections of 15 cases of endosalpingiosis involving nonneoplastic tissues were subjected to GATA3 immunohistochemistry. Nuclear GATA3 labeling was scored as percentage and intensity labeling, with any labeling considered positive; GATA3 labeling was recorded in all cells present in the sections.

RESULTS.—

Half (47%, n = 7 of 15) of the endosalpingiosis cases involved lymph nodes (2 axillary, 5 pelvic) and half (53%, n = 8 of 15) involved pelvic organs or soft tissue (3 myometrial, 2 paratubal, 2 periadnexal soft tissue, and 1 pelvic sidewall). GATA3 immunohistochemistry was negative in all cases of endosalpingiosis, with intact, positive control labeling in lymphocytes. The benign fallopian tube epithelium present on the sections of paratubal endosalpingiosis displayed focal (<5%), weak labeling for GATA3, specifically within the ciliated and secretory cells.

CONCLUSIONS.—

These findings support the diagnostic utility of GATA3 immunohistochemistry and its use in a targeted immunopanel to resolve the differential diagnosis of metastatic low-grade mammary carcinoma (GATA3+) and nodal endosalpingiosis (GATA3-).

Improved detection of sentinel lymph node metastases allows reliable intraoperative identification of patients with extended axillary lymph node involvement in early breast cancer

An improved procedure that allows accurate detection of negative sentinel lymph node (SLN) and of SLN macrometastases during surgery would be highly desirable in order to protect patients from further surgery and to avoid unnecessary costs. We evaluated the accuracy of an intraoperative procedure that combines touch imprint cytology (TIC) and subsequent frozen section (FS) analysis. 2276 SLNs from 1072 patients with clinical node-negative early breast cancer were evaluated during surgery using TIC. Only cytologically-positive SLN were subsequently analysed with a single FS, preserving cytologically-negative SLN for the final postoperative histological diagnosis. Sensitivity, specificity and the accuracy of this approach were analysed by comparing the results from intra- and postoperative SLN and axillary node evaluation. This intraoperative method displayed 100% specificity for SLN metastases and was significantly more sensitive for prognostically relevant macrometastases (85%) than for micrometastases (10%). Sensitivity was highest for patients with two or more positive LNs (96%) than for those with only one (72%). 98% of the patients with final pN2a-pN3a were already identified during surgery. Patients who received primary axillary lymph node dissection had significantly more frequent metastases in further LNs (44.6%). Sensitivity was highest for patients with luminal-B, HER2+ and triple negative breast cancer and for any subtype if Ki-67 > 40%. TIC and subsequent FS of cytologically-positive SLNs is highly reliable for detection of SLN macrometastases, and allows accurate identification of patients with a high risk of extended axillary involvement during surgery, as well as accurate histological diagnosis of negative SLN.

Breast Sentinel Lymph Node Frozen Section Practice: An Enterprise Audit as a Guide for Moving Forward

CONTEXT.—

In recent years, there has been a shift to less aggressive surgical management of the axilla in breast cancer. Consequently, sentinel lymph node evaluation by frozen section (FS) has declined. Additionally, there has been an impetus to decrease efforts in identifying small sentinel lymph node metastases.

OBJECTIVES.—

To critically evaluate our enterprise performance in evaluating axillary sentinel lymph nodes submitted for FS prior to considering changes in processing.

DESIGN.—

A retrospective review (August 1, 2017-July 31, 2019) was conducted to identify sentinel and nonsentinel lymph nodes from 1 academic institution and 2 community sites. Cases were evaluated for grossing technique and discordance between FS and permanent section (PS) due to sampling and/or interpretive error. Clinicopathologic features were assessed.

RESULTS.—

Lymph nodes from 426 patients with 432 neoplasms were sent for FS. Serial sectioning at 2-mm intervals was adhered to in 338 of 432 (78.2%). Serial sectioning was significantly lower at the community sites (14 of 60; 23.3%) versus at the academic institution (324 of 372; 87.1%; P < .001). Discordant cases were all false negatives (21 of 432; 4.8%). A total of 7 of 21 false negatives (33.3%) had macrometastatic (>2 mm) disease; of these, 3 were post-neoadjuvant chemotherapy, 3 were neither serially sectioned nor posttherapy, and 1 was a small (0.3-cm) focus. A total of 15 of 16 false negatives due to sampling error were detected on the first permanent section level.

CONCLUSIONS.—

Standard serial sectioning of sentinel lymph nodes at 2-mm intervals resulted in infrequent false negatives due to macrometastatic disease. A single additional permanent section level is reasonable, given adherence to serial sectioning.

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.

Sectioning protocol determines accuracy of intraoperative pathological examination of sentinel lymph node in cervical cancer: A systematic review and meta-analysis

OBJECTIVES

To determine the diagnostic performance and optimal protocol of frozen section examination (FSE) in SLNB for cervical cancer.

METHODS

PubMed, EMBASE, Web of Science, Cochrane Library, Wanfang Data and China National Knowledge Infrastructure were searched from inception to July 30, 2019, for studies concerning SLNB with FSE in cervical cancer. Sensitivity of FSE in detecting SLN metastasis was the primary diagnostic indicator for evaluation.

RESULTS

The pooled sensitivity of FSE among 31 eligible studies (1887 patients) was 0.77 (95% CI 0.66-0.85) with high heterogeneity (I² = 69.73%). Two representative sectioning protocols for FSE were identified from 26 studies, described as equatorial (E-protocol, SLN was bisected) and latitudinal (L-protocol, SLN was cut at intervals). Meta-regression showed that FSE protocol was the only source of heterogeneity (p < 0.001). The pooled sensitivity was 0.86 (95% CI 0.79-0.91, I² = 0%) and 0.59 (0.46-0.72, I² = 58.47%) for FSE using L- (13 studies, 650 patients) and E- (13 studies, 1047 patients) protocol, respectively. Among the available data, marcometastases (>2 mm) were missed in 4 and 20 patients; small-volume metastases (≤2 mm) were detected in 13 and 2 patients, respectively, under L- and E-protocol. The pooled sensitivity of FSE using L-protocol would reach 0.97 (95% CI 0.89-0.99) if only marcometastases were considered. These findings were robust to sensitivity analyses.

CONCLUSION

The sectioning protocol determines the accuracy of FSE in SLNB. With L-protocol, FSE can provide precise intraoperative pathology for SLNB, which enables immediate decision-making for individualized managements.

Lymph Node Predictive Model with in Vitro Ultrasound Features for Breast Cancer Lymph Node Metastasis

Ultrasound diagnosis of axillary lymph nodes has the advantages of ease, convenience and low cost; however, most previous studies evaluated lymph node metastasis of the entire axilla rather than the association between the ultrasound features of a single lymph node and its pathology. This prospective study was performed to explore the ultrasound features of lymph nodes observed in bionic medium in vitro and to develop a lymph node-specific model for prediction of metastasis based on analysis of the association between the ultrasound features and pathology of each lymph node. From November 1, 2017 to December 19, 2017, 373 nodes (54 patients) were enrolled into the modeling group; from December 20, 2017 to January 12, 2018, 139 lymph nodes (22 patients) were enrolled into the validation group. Lymph nodes from sentinel lymph node biopsy or axillary lymph node dissection were enrolled. Individual lymph nodes were placed in bionic medium and observed separately using ultrasound. Traditional ultrasound features of metastatic nodes (long axis, short axis, cortical thickness and hilum loss) were recorded, and the longitudinal-to-transverse axis ratio (L/T) and cortical proportion were calculated. Pathologic results specific to each lymph node were recorded. On the basis of two-level binary logistic regression, independent predictors of lymph node metastasis in the modeling group were lymph node long axis (p = 0.004), short axis (p < 0.001), L/T (p = 0.006), cortical thickness (p = 0.001) and hilum loss (p < 0.001). When analysis was done at the node level, the areas under the curve of the modeling and validation groups were 0.97 and 0.75, respectively. When validation was done at the patient level, the areas under the curve of the modeling and validation groups were 0.96 and 0.93, respectively. The model for prediction of metastasis based on the ultrasound features and pathology of each lymph node is of good predictive value for lymph node metastasis.

Is Necessary Intraoprative Frozen Section In Sentinel Lymph Node Biopsy For Breast Cancer Patients?

Background:

Improvements in the process of staging and surgical treatment of axillary lymph nodes in recent years, have led to the use of intra operative frozen section pathology to examine the sentinel lymph node biopsy in breast cancer patients.

Materials and Methods:

we evaluated the results of the Sentinel biopsy in 102 patients with early stage breast cancer, which were negative clinical lymph nodes, and analyzing the true positive and false negative rate, diagnostic accuracy of frozen section lymph node biopsy. It also studied the factors affecting the sentinel and non-sentinel lymph nodes in patients treated by axillary lymph dissection.

Results:

In this study, we investigated 102 patients’ stage 1and 2 breast cancer with clinical negative axillary lymph node and candidates for sentinel lymph node biopsy, were placed under investigation. 15.7 % of the real positive results of sentinel and 62.7 % of the real negative and 2 % false positives and 20.9 % false negative results and% 78. 4 diagnostic accuracy, has been frozen section. Among the patients who were initially or delayed in the axillary dissection, 37% had more than two lymph nodes. While in general, 16.7% of patients had a need for axillary lymph node dissection based on z11 criteria. Lymph-vascular invasion was a major contributor to lentil involvement in Sentinel and non-Sentinel nodes.

Conclusion:

Frozen section pathology during the operation of sentinel lymph node biopsy has been initiated to prevent the need for a reoperation in early stage breast cancer patients. However, due to low tumor burden in patients who are candidates for this procedure, and the constraints in the initial sections and their false negative results, also the removal of frozen section will not have an effect on the rate of increasing reoperation and can be effective in reducing the time and cost of surgery.

Is the frozen section examination for sentinel lymph node necessary in early breast cancer patients?

PURPOSE

Sentinel lymph node (SLN) biopsy (SLNB) is widely performed for axillary staging in patients with breast cancer. Based on the results of frozen section examination (FSE), surgeons can decide to continue further axillary dissections. This study aimed to verify the accuracy of FSE for SLNs.

METHODS

We reviewed the records of 4,219 patients who underwent SLNB for primary invasive breast cancer between 2007 and 2016 at the Severance Hospital. We evaluated factors associated with the false-negative results of FSE for SLNs using the Generalized Estimating Equations model.

RESULTS

A total of 1,397 SLNs from 908 patients were confirmed to be metastatic. Seventy-one patients (1.7%) had confirmed pathologic N2 or N3 stage. Among metastatic SLNs, micrometastasis was found in 234 (16.8%). The overall accuracy of SLNB was 98.5%. The sensitivity and false-negative rate of FSE were 86.4% and 13.6%, respectively. Several clinicopathological factors, including the size of SLN metastases, suspicious preoperative axillary lymph nodes, and luminal B subtype, were associated with a higher rate of false-negative results.

CONCLUSION

Most patients were not indicated for axillary lymph node dissection. Some patients may show transition in their permanent pathology due to the size of the metastatic node. However, the false-negative results of FSE for SLNs based on the size of the metastatic node did not change our practice. Therefore, intraoperative FSE for SLN should not be routinely performed for all breast cancer patients.

Frozen-Section Checklist Implementation Improves Quality and Patient Safety

OBJECTIVES

An intraoperative consultation (IOC) checklist was developed and implemented aimed at standardizing slide labeling and monitoring metrics central to quality and safety in surgical pathology.

DESIGN

Data were collected for all IOC cases over a 9-month period. Slide labeling defect rates and IOC turnaround time (TAT) were recorded and compared for the pre- and postimplementation periods.

RESULTS

In total, 839 IOC cases were analyzed. Preintervention slide labeling showed that 85% of cases contained at least one defect (n = 565). Postintervention data revealed that 27% of cases contained at least one defect (n = 274). The improvement was statistically significant (P < .001). Mean TAT was 21.6 minutes preintervention vs 23.2 minutes postintervention, and the change was insignificant (P = .071).

CONCLUSIONS

The implementation of a standardized IOC reduced slide labeling error. This improvement did not affect mean TAT and may have the increased quality of IOC TAT data reporting. Other metrics affecting patient safety and quality were monitored and standardized.

Comparison of CK-IHC assay on serial frozen sections, the OSNA assay, and in combination for intraoperative evaluation of SLN metastases in breast cancer

BACKGROUND

Intraoperative evaluations of sentinel lymph node (SLN) metastases are performed for providing appropriate and immediate axillary treatments in breast cancer patients who do not meet Z0011 criteria; however, standard intraoperative procedure has not yet been established.

METHODS

We consecutively performed intraoperative evaluation for SLN metastases using both a cytokeratin immunohistochemistry (CK-IHC) assay on serial frozen sections and a one-step nucleic acid amplification (OSNA) assay of the remaining whole node in patients with invasive breast cancer. In this article, we compared the intraoperative diagnostic ability of CK-IHC assay, the OSNA assay, and in combination.

RESULTS

Between August 2009 and May 2017, 1,103 SLNs from 499 consecutive clinically node-negative invasive breast cancers were intraoperatively evaluated for SLN metastases using an OSNA and CK-IHC assay. The detection rates of SLN metastases by the OSNA and CK-IHC assays and in combination were 11.8, 12.1, and 14.5%, respectively. The concordance rate between the intraoperative SLN findings of the OSNA and CK-IHC assays was 94.9% (95% confidence interval 93.6-96.2%). The false negative rate for the OSNA assay was 3.1% (30/973), including 3 (0.3%) macrometastases and 27 (2.8%) micrometastases, and for the CK-IHC assay was 2.7% (26/969), including 1 (0.1%) OSNA ++ and 25 (2.6%) OSNA +.

CONCLUSIONS

The CK-IHC assay and the OSNA assay have compatible diagnostic abilities in intraoperative evaluations for SLN metastases. The low incidence of false negative results with limited disease burden suggests that both assays can be reliable techniques for intraoperative diagnoses of SLN metastases in breast cancer patients.

Frozen section evaluation of sentinel lymph nodes in breast carcinoma: a retrospective analysis

Objective

To determine the false-negative rate, sensitivity, and diagnostic accuracy of the frozen section analysis of the sentinel lymph node (SLN) biopsy in early-stage breast cancer compared to the definitive section and to identify the factors that could be associated with the appearance of false-negative cases. Secondarily, to evaluate the pathological results of cases submitted to completion axillary lymph node dissection (ALND) for positive SLN.

Methods

We performed a five-year review of cases (2011–2015), including patients with early-stage breast cancer undergoing SLN biopsy, with frozen section evaluation and subsequent definitive pathological analysis. These results were compared to calculate the false-negative rate and the factors associated with it. The histopathological findings were also evaluated in patients submitted to completion ALND.

Results

A total of 281 patients were evaluated, identifying 18 cases with frozen section results as false negative (false-negative rate: 23.7%), and 55.5% of these cases were micrometastases. The false-negative rate in SLN with macrometastasis was 13.1% and for micrometastasis cases was 66.7% (p < 0.001). True-positive patients that were submitted to completion ALND had additional axillary lymph nodes with metastases in 28% of cases, whereas the group of false negatives had additional positive axillary lymph nodes in 40% of patients (p = 0.62).

Conclusion

Frozen section analysis had a false-negative rate acceptable in SLN biopsy in our institution, and the micrometastasis in the SLN was the most important factor associated with the appearance of this phenomenon.