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Zhang L, Hu J, Ali Zirakzadeh A, Rosvall J, Hedlund M, Hu PS, P A Wallin R, Sherif A, Winqvist O. Detection of micro-metastases by flow cytometry in lymph nodes from patients with penile cancer. BMC Urol 2018; 18:86. [PMID: 30290760 PMCID: PMC6173905 DOI: 10.1186/s12894-018-0399-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 09/23/2018] [Indexed: 11/21/2022] Open
Abstract
Background The tumor draining lymph node concept was first described in penile cancer for staging. Immunohistochemistry and histopathology evaluations are routinely used in clinical practice to examine lymph nodes for metastasis. However, these methods are time-consuming with low diagnostic accuracy and micro-metastases might be missed. In this study, we aim to evaluate detection of metastatic cells in draining lymph nodes by flow cytometry. Methods To assess the sensitivity of micro-metastasis detection by FACS (Fluorescence-activated cell sorting), HeLa cells were titrated into Peripheral blood mononuclear cells (PBMCs) and expression of pan-cytokeratin AE1/AE3 was analyzed. Single cell suspensions were separately prepared from 10 regional lymph nodes obtained from 5 patients with invasive penile cancer undergoing radical surgery and lymph node dissection. Lymph node dereived cells were examined for cell surface expression of EpCAM, E-cadherin and intracellular expression of pan-cytokeratin AE1/AE3 by FACS. Results Ten lymph nodes from 5 penile cancer patients were investigated in a head-to-head comparison between FACS and pathology examination of sections. All metastatic lymph nodes verified by pathology examination were also identified by FACS. Two additional lymph nodes with micro-metastases were diagnosed by FACS only. Conclusions FACS analyses of pan-cytokeratin AE1/AE3 stained single cells from tumor draining lymph nodes can be used to detect micro-metastases in patients with penile cancer patients.
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Affiliation(s)
- Lu Zhang
- Department of Medicine, Immunology and Allergy Unit, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Jin Hu
- Department of Medicine, Immunology and Allergy Unit, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - A Ali Zirakzadeh
- Department of Medicine, Immunology and Allergy Unit, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Jesper Rosvall
- Department of Urology, South General Hospital, Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Mats Hedlund
- Department of Urology, South General Hospital, Karolinska Institutet, Stockholm, Stockholm, Sweden
| | - Ping Sheng Hu
- Cancer Biotherapy Center, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Robert P A Wallin
- Department of Medicine, Immunology and Allergy Unit, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Amir Sherif
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Ola Winqvist
- Department of Medicine, Immunology and Allergy Unit, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
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Shin ET, Joehlin-Price AS, Agnese DM, Zynger DL. Minimal Clinical Impact of Intraoperative Examination of Sentinel Lymph Nodes in Patients With Ductal Carcinoma In Situ: An Opportunity for Improved Resource Utilization. Am J Clin Pathol 2017; 148:374-379. [PMID: 29016707 DOI: 10.1093/ajcp/aqx089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES There is little information regarding sentinel lymph node (SLN) frozen-section examination in patients with a history of ductal carcinoma in situ (DCIS). We evaluated the usage, clinical impact, and pathology resources used for SLN cryosectioning in mastectomy cases with a DCIS history. METHODS Mastectomies with SLNs submitted from 2012 to 2013 at a tertiary care center were analyzed. Medicare reimbursement was used to estimate pathology health care expenditures of intraoperative frozen sections. RESULTS There was no difference in the rate of SLN frozen-section examination or parts submitted, total blocks frozen, total blocks submitted, or total SLNs identified per case between the DCIS (n = 139) and invasive (n = 369) groups. Nine patients with DCIS had SLN metastases (three macrometastases, two micrometastases, and four isolated tumor cells), all of which were examined by frozen section. Only the macrometastases were identified by cryosectioning, which led to two synchronous axillary lymph node dissections that did not yield any additional positive nodes. A total of $19,313 was spent for pathology per DCIS patient with surgical management affected, whereas only $1,019 was spent per invasive carcinoma patient affected. CONCLUSIONS Decreasing SLN frozen-section use in patients with a history of DCIS represents an opportunity for pathology cost containment.
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Affiliation(s)
| | | | - Doreen M Agnese
- Surgical Oncology, The Ohio State University Medical Center, Columbus
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Van Berckelaer C, Huizing M, Van Goethem M, Vervaecke A, Papadimitriou K, Verslegers I, Trinh BX, Van Dam P, Altintas S, Van den Wyngaert T, Huyghe I, Siozopoulou V, Tjalma WAA. Preoperative ultrasound staging of the axilla make's peroperative examination of the sentinel node redundant in breast cancer: saving tissue, time and money. Eur J Obstet Gynecol Reprod Biol 2016; 206:164-171. [PMID: 27697620 DOI: 10.1016/j.ejogrb.2016.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 08/31/2016] [Accepted: 09/10/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the role of preoperative axillary staging with ultrasound (US) and fine needle aspiration cytology (FNAC). Can we avoid intraoperative sentinel lymph node (SLN) examination, with an acceptable revision rate by preoperative staging? DESIGN This study is based on the retrospective data of 336 patients that underwent US evaluation of the axilla as part of their staging. A FNAC biopsy was performed when abnormal lymph nodes were visualized. Patients with normal appearing nodes on US or a benign diagnostic biopsy had removal of the SLNs without intraoperative pathological examination. We calculated the sensitivity, specificity and accuracy of US/FNAC in predicting the necessity of an axillary lymphadenectomy. Subsequently we looked at the total cost and the operating time of 3 models. Model A is our study protocol. Model B is a theoretical protocol based on the findings of the Z0011 trial with only clinical preoperative staging and in Model C preoperative staging and intraoperative pathological examination were both theoretically done. sentinel node, staging, ultrasound, preoperative axillary staging, FNAC, axilla RESULTS: The sensitivity, specificity and accuracy are respectively 0.75 (0.66-0.82), 1.00 (0.99-1.00) and 0.92 (0.88-0.94). Only 26 out of 317 (8.2%) patients that successfully underwent staging needed a revision. The total cost of Model A was 1.58% cheaper than Model C and resulted in a decrease in operation time by 9,46%. The benefits compared with Model B were much smaller. CONCLUSION Preoperative US/FNAC staging of the axillary lymph nodes can avoid intraoperative examination of the sentinel node with an acceptable revision rate. It saves tissue, reduces operating time and decreases healthcare costs in general.
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Affiliation(s)
- Christophe Van Berckelaer
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Manon Huizing
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Mireille Van Goethem
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Andrew Vervaecke
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Konstantinos Papadimitriou
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Inge Verslegers
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Bich X Trinh
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Peter Van Dam
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Sevilay Altintas
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Tim Van den Wyngaert
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Ivan Huyghe
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Vasiliki Siozopoulou
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Wiebren A A Tjalma
- Multidisciplinary Breast Clinic Antwerpen, Antwerp University Hospital-University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium.
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Detection of micrometastases by flow cytometry in sentinel lymph nodes from patients with renal tumours. Br J Cancer 2016; 115:957-966. [PMID: 27599044 PMCID: PMC5061909 DOI: 10.1038/bjc.2016.279] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/04/2016] [Accepted: 08/09/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Stage is an important prognostic factor in renal tumours and dissemination to regional lymph nodes is associated with poor outcomes. Lymph nodes are routinely assessed by immunohistochemistry and microscopic evaluation, a time-consuming process where micrometastases might go undiagnosed. We evaluate an alternative method for detecting metastatic cells in sentinel nodes (SNs) by flow cytometry. METHODS A total of 15 nodes from 5 patients diagnosed with renal tumours were analysed by flow cytometry. Staining for the intracellular marker cytokeratin 18 (CK18) with the surface markers carbonic anhydrase IX (CA9) and Cadherin 6 were used in flow cytometry analysis. Peripheral blood mononuclear cells (PBMCs) with the addition of known concentrations of cancer cell lines were analysed to investigate the sensitivity of micrometastasis detection. RESULTS Stability of the assay was marked by low intra-assay variability (coefficient of variance ⩽16%) and low inter-assay variability (R2=0.9996-1). Eight nodes in four patients were positive for metastasis; six of them were considered being micrometastatic. These metastases were undetected by routine pathology and the patients were restaged from pN0 to pN1. CONCLUSIONS Flow cytometry is able to detect micrometastases in lymph nodes of renal tumour patients that were undetected under H&E examination.
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Saruta Y, Puig-Junoy J. Cost and Budget Impact Analysis of an Accurate Intraoperative Sentinel Lymph Node Diagnosis for Breast Cancer Metastasis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2016; 14:323-35. [PMID: 27043330 DOI: 10.1007/s40258-016-0235-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Conventional intraoperative sentinel lymph node biopsy (SLNB) in breast cancer (BC) has limitations in establishing a definitive diagnosis of metastasis intraoperatively, leading to an unnecessary second operation. The one-step nucleic amplification assay (OSNA) provides accurate intraoperative diagnosis and avoids further testing. Only five articles have researched the cost and cost effectiveness of this diagnostic tool, although many hospitals have adopted it, and economic evaluation is needed for budget holders. OBJECTIVE We aimed to measure the budget impact in Japanese BC patients after the introduction of OSNA, and assess the certainty of the results. METHODS Budget impact analysis of OSNA on Japanese healthcare expenditure from 2015 to 2020. Local governments, society-managed health insurers, and Japan health insurance associations were the budget holders. In order to assess the cost gap between the gold standard (GS) and OSNA in intraoperative SLNB, a two-scenario comparative model that was structured using the clinical pathway of a BC patient group who received SLNB was applied. Clinical practice guidelines for BC were cited for cost estimation. RESULTS The total estimated cost of all BC patients diagnosed by GS was US$1,023,313,850. The budget impact of OSNA in total health expenditure was -US$24,413,153 (-US$346 per patient). Two-way sensitivity analysis between survival rate (SR) of the GS and OSNA was performed by illustrating a cost-saving threshold: y ≅ 1.14x - 0.16 in positive patients, and y ≅ 0.96x + 0.029 in negative patients (x = SR-GS, y = SR-OSNA). Base inputs of the variables in these formulas demonstrated a cost saving. CONCLUSION OSNA reduces healthcare costs, as confirmed by sensitivity analysis.
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Affiliation(s)
- Yuko Saruta
- Barcelona School of Management, Pompeu Fabra University, C. Ramón Trias Fargas 25-27, Edificio Jaume I, Barcelona, 08005, Spain.
| | - Jaume Puig-Junoy
- Department of Economics and Business, Research Centre for Health and Economics (CRES), Pompeu Fabra University, Barcelona, Spain
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Brambilla T, Fiamengo B, Tinterri C, Testori A, Grassi MM, Sciarra A, Abbate T, Gatzemeier W, Roncalli M, Di Tommaso L. One-Step Nucleic Acid Amplification in Breast Cancer Sentinel Lymph Node: A Single Institutional Experience and a Short Review. Front Med (Lausanne) 2015; 2:37. [PMID: 26131451 PMCID: PMC4469115 DOI: 10.3389/fmed.2015.00037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/20/2015] [Indexed: 11/16/2022] Open
Abstract
Sentinel lymph node (SLN) examination is a standard in breast cancer patients, with several methods employed along its 20 years history, the last one represented by one-step nucleic acid amplification (OSNA). The latter is a intra-operative molecular assay searching for CK19 mRNA as a surrogate of metastatic cells. Our 3 years experience with OSNA (1122 patients) showed results overlapping those recorded in the same institution with a morphological evaluation (930 patients) of SLN. In detail, the data of OSNA were almost identical to those observed with standard post-operative procedure in terms of patients with positive SLN (30%) and micrometastatic/macrometastatic involvement of SLN (respectively, 38–45 and 62–55%). By contrast, when OSNA was compared to the standard intraoperatory procedure, it was superior in terms of accuracy, prompting the use of this molecular assay as a very valid, and reproducible for intra-operative evaluation of SLN. Further possibilities prompting the use of OSNA range from adhesion to quality control programs, saving of medical time, ability to predict, during surgery, additional nodal metastasis, and molecular bio-banking.
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Affiliation(s)
- Tatiana Brambilla
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Barbara Fiamengo
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Corrado Tinterri
- Senology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Alberto Testori
- Senology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | | | - Amedeo Sciarra
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Tommaso Abbate
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | | | - Massimo Roncalli
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
| | - Luca Di Tommaso
- Pathology Unit, Humanitas Clinical and Research Hospital , Milan , Italy
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Poling JS, Tsangaris TN, Argani P, Cimino-Mathews A. Frozen section evaluation of breast carcinoma sentinel lymph nodes: a retrospective review of 1,940 cases. Breast Cancer Res Treat 2014; 148:355-61. [PMID: 25318925 DOI: 10.1007/s10549-014-3161-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 10/01/2014] [Indexed: 12/19/2022]
Abstract
Many sentinel lymph node biopsies (SLNBs) are evaluated intraoperatively by frozen section, which may impact the need for further axillary dissection (AD). However, the need for AD in patients with small metastases has been recently called into question, meaning that frozen SLNB may be unnecessary. Furthermore, frozen section can compromise tissue for further study. At our institution, we grossly evaluate all SLNB and freeze half of the node. Here, we evaluate the frozen SLNB discrepancy rate using this method, focusing on cause of discrepancy and need for further surgery. We reviewed surgical pathology records for all breast cancer resections with frozen section of SLNB examined from 2003 to 2012. For cases with a frozen section discrepancy, we compiled clinicopathologic data. In total, 1,940 cases involved frozen section evaluation of SLNB. In 95 cases (4.9% of total cases, 23.8% of positive node cases), the SLNB was called negative on frozen but positive on final examination (false negatives). The majority of missed metastases are isolated tumor cells or micrometastases. A trend was observed toward fewer patients receiving completion AD after a discrepant frozen SLNB in the later years of the study. The protocol of freezing half of a SLNB is a reasonable method, with results similar to or better than other studies. The main adverse outcome is the need for separate AD; however, additional positive nodes are uncommon. The trend of fewer patients getting additional AD after a discrepant frozen SLNB suggests that clinicians may be using this information differently recently.
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Affiliation(s)
- Justin S Poling
- Department of Pathology, The Johns Hopkins Hospital, 401 North Broadway Street, Weinberg 2242, Baltimore, MD, 21231, USA
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