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

Predictors of recurrence in breast cancer patients with pathological partial response

OBJECTIVE

Patients with residual disease after neoadjuvant chemotherapy have a relative risk of developing recurrence. This study investigates the risk factors for recurrence in locally advanced breast cancer patients with residual disease and evaluates survival analysis.

METHODS

This is a retrospective, single-center study. Breast cancer patients who failed to achieve a pathological complete response after neoadjuvant chemotherapy were included. Demographic, clinicopathological, and treatment characteristics were evaluated to identify predictive factors of recurrence and survival analysis.

RESULTS

We included 205 patients in this study. After a median of 31 months of follow-up, 10 patients died, and 20 developed distant metastasis. Disease-free survival and disease-specific survival were 73.8% and 83.1%, respectively. Lymphovascular invasion and non-luminal subtype were independent predictors of locoregional recurrence. In situ carcinoma, lymphovascular invasion, ypTIII stage, and non-luminal molecular subtypes were independent predictors of disease-free survival. The only independent factor affecting disease-specific survival was cNII-III. The number of involved lymph nodes was an independent predictor of disease-free survival in patients without complete axillary response.

CONCLUSION

Factors affecting disease-specific survival and disease-free survival were cNII-III and the number of involved lymph nodes, respectively. Patients with non-luminal, large residual tumors with in situ carcinoma, lymphovascular invasion, clinically positive axilla, and residual nodal involvement have a high relative risk for recurrence and may benefit from additional treatments.

A nomogram for predicting three or more axillary lymph node involvement before breast cancer surgery

Based on the American College of Surgeons Oncology Group (ACOSOG)-Z0011, a useful nomogram has been constructed to identify patients who do not require intraoperative frozen sections to evaluate sentinel lymph nodes in the previous study. This study investigated the developed nomogram by ultrasonography (US) and positron emission tomography (PET)/computed tomography (CT) as a modality. In the training set, 89/1030 (8.6%) patients had three or more positive nodes. Larger tumor size, higher grade ultrasonographic ALN classification, and findings suspicious of positive ALN on PET/CT were associated in multivariate analysis. The areas under the receiver operating characteristic curve (AUC) of the nomogram were 0.856 [95% CI 0.815-0.897] in the training set. The AUC in the validation set was 0.866 [95% CI 0.799-0.934]. Application of the nomogram to 1067 patients who met the inclusion criteria of ACOSOG-Z0011 showed that 90 (8.4%) patients had scores above the cut-off and a false-negative result was 37 (3.8%) patients. And the specificity was 93.8%, and the negative predictive value was 96.4%. The upgraded nomogram improved the predictive accuracy, using only US and PET/CT. This nomogram is useful for identifying patients who do not require intraoperative analysis of sentinel lymph nodes and considering candidates for identifying neoadjuvant chemotherapy. The patients consisted of clinical T1-2 and node-negative invasive breast cancer. The training and validation set consisted of 1030 and 781 patients, respectively. A nomogram was constructed by analyzing factors related to three or more axillary lymph node metastases. The patients who matched the ACOSOG-Z0011 criteria were selected and applied to the new nomogram.

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.

Critical Review of the Current Evidence on Sentinel Node Biopsy in Oral Cancer

PURPOSE OF REVIEW

With contemporary surgery of the cN0 neck in early oral cancer becoming more selective, sentinel node biopsy (SNB) is gaining popularity as a possible alternate option to elective neck dissection (END). This review attempts to critically appraise the current evidence and highlight pertinent arguments for the use of SNB in early oral cancers.

RECENT FINDINGS

Based on the recent randomized trials, it is imperative to perform an END at the time of primary resection in cN0 oral cancers. The much criticized false negative rate of SNB can be argued to be equal to the regional failure rate after END for pN0 necks, possibly making a case for SNB due to the reduction in number of neck dissections. There still lies ambiguity on the technique, protocols, and benefit of SNB over END. The role of extended histopathological techniques and the implications of micrometastasis and isolated tumor cells for treatment intensification remain questionable. Currently, SNB is an intermediary between routine imaging and END that needs to evolve before it can become a practice changing alternative to END itself. More efforts are needed in standardizing the protocols for SNB.

After neoadjuvant therapy, axillary sentinel lymph node frozen sections from breast cancer patients are accurately diagnosed using telepathology

Context

Telepathology is a digital, microscope-independent method of diagnosing pathology from scanned slides. Frozen sections (FS) can be performed and read by a pathologist at any site. At our institution, telepathology is used for diagnosis of frozen sections of sentinel lymph nodes (SLN) in patients who have undergone neoadjuvant chemotherapy and are enrolled in a clinical trial.

Objective

We investigated the accuracy of diagnosing SLN frozen sections in the neoadjuvant setting using telepathology.

Design

SLN were entirely submitted for frozen section. A pathology assistant prepared the frozen and scanned the slides using VisionTek M6 digital microscope ecosystem (East Dundee, IL). Cases were interpreted by trained, board-certified pathologists. All frozen sections remnants were submitted for formalin-fixed paraffin-embedded permanent sections. Frozen section diagnoses using telepathology were compared to final pathology. Turn-around time from specimen collection to frozen section diagnosis was recorded.

Results

54 SLN from 22 breast neoadjuvant cases were diagnosed via telepathology from March 2017 to July 2019. 95% of SLNs interpreted as negative on frozen section and on permanents. A definitive diagnosis could not be rendered on six SLNs; diagnosed “atypical” at frozen. Sensitivity and specificity were 80% and 100% respectively with accuracy of 95.8%. The false-negative rate was 5%. There were no false positives. The average turn-around time was over an hour.

Conclusions

Telepathology is an accurate method of diagnosing SLN frozen sections in the neoadjuvant setting, but lobular carcinomas and treatment effect pose diagnostic challenges and the time to report results is increased compared to standard microscopy.

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.

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.

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.

Results from Survey to Assess Current Trends in Surgical Practice in the Management of Women with Early Stage Cervical Cancer within the BGCS Community with an Emphasis on Routine Frozen Section Examination

In the UK, more than 3,200 new cases of cervical cancer are diagnosed each year. Early stage cervical cancer (IA2-IB1) treatment comprises central surgery mainly in the form of radical hysterectomy or fertility sparing surgery including trachelectomy as well as systematic pelvic lymphadenectomy to detect metastases and adjust treatment accordingly. Given the variation in determining the lymph node (LN) status, a major prognosticator, we reviewed the current UK practice of LN assessment in women undergoing surgery for early cervical cancer. A 7-question, web-based survey, screened by the BGCS committee, was circulated amongst BGCS members. The overall response rate was 51%. Only 12.5% of the respondents routinely performed frozen section examination (FSE); the main reasons for not doing FSE were the pressure on theatre time (54.5%) and the lack of available facilities (48.5%). When positive pelvic nodal disease was detected, in 21 out of 50 (42%) the planned radical hysterectomy (RH) was aborted. More than 70% of the respondents routinely performed RH without any prior resort to pelvic lymphadenectomy. Pretreatment surgical para-aortic LN assessment was performed by 20% of the respondents. The survey confirms the diversity of the UK practice patterns in the surgical treatment of early cervical cancer.

The Empirical Foundations of Telepathology: Evidence of Feasibility and Intermediate Effects

INTRODUCTION

Telepathology evolved from video microscopy (i.e., "television microscopy") research in the early 1950s to video microscopy used in basic research in the biological sciences to a basic diagnostic tool in telemedicine clinical applications. Its genesis can be traced to pioneering feasibility studies regarding the importance of color and other image-based parameters for rendering diagnoses and a series of studies assessing concordance of virtual slide and light microscopy diagnoses. This article documents the empirical foundations of telepathology.

METHODS

A selective review of the research literature during the past decade (2005-2016) was conducted using robust research design and adequate sample size as criteria for inclusion.

CONCLUSIONS

The evidence regarding feasibility/acceptance of telepathology and related information technology applications has been well documented for several decades. The majority of evidentiary studies focused on intermediate outcomes, as indicated by comparability between telepathology and conventional light microscopy. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include use of telepathology and whole slide imaging for teaching, research, and outreach to resource-limited countries. Challenges still exist, however, in terms of use of telepathology as an effective diagnostic modality in clinical practice.

Secretory breast carcinoma in a 12-year-old girl: A case report

Secretory breast carcinoma (SBC) is a rare tumor that was originally described in children and adolescent women, with a characteristic morphology and controversy regarding the choice of treatment. This unusual breast cancer subtype generally has a favorable prognosis, although several cases have been described in adults with increased tumor aggressiveness and a risk of metastases. Surgery is considered the most appropriate treatment for this pathology. The present study describes the case of a 12-year-old female who presented with a painless lump in the left breast, and subsequently underwent a biopsy of the sentinel lymph node and a partial resection of the left breast (breast-conserving therapy). Periodic follow-up examinations after completion of the surgical and chemotherapeutic treatment have shown no evidence of either local regression or distant metastases and, one year later, the patient remains free of the disease. This study suggests that local excision with sentinel lymph node mapping may be a suitable therapeutic approach for children with SBC

An improved axillary staging system using the OSNA assay does not modify the therapeutic management of breast cancer patients

The one-step nucleic acid amplification (OSNA) assay is a molecular procedure that can identify deposits of breast cancer (BC) cells in the sentinel lymph node (SLN). We examined the consistency of the OSNA assay with a classic hematoxylin-eosin (H&E)-based immunohistochemistry (IHC) study and evaluated how OSNA-based axillary staging might impact the therapeutic management of BC patients. SLN biopsy results were considered to be positive in 60 patients (40%) in the OSNA group (N = 148) and in 43 (28%) patients in the IHC cohort (N = 153, p = 0.023). There was no difference in the macrometastasis (22% for OSNA, 15% for H&E, p = 0.139) or micrometastasis (19% for OSNA, 13% for H&E, p = 0.166) rates, but we found statistically significant differences in the number of isolated tumor cells (1% for OSNA, 11% for H&E, p < 0.001). There were no differences in the administration rate of adjuvant systemic therapy between the OSNA (66% in the SLN(+) patients) and the H&E (74% in the SLN(+) patients) groups (p = 0.159). The OSNA assay allows for the detection of SLN metastases more precisely than conventional pathologic methods but does not alter the therapeutic management of SLN(+) BC patients.