Evaluation of immunohistochemistry and multiple-level sectioning in sentinel lymph nodes from patients with breast cancer

Meta-analysis of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initial biopsy-proven node-positive breast cancer

BACKGROUND

Neoadjuvant chemotherapy for breast cancer has the potential to achieve a pathological complete response in up to 40 per cent of patients, converting disease that was initially node-positive to node-negative. This has raised the question of whether sentinel lymph node biopsy could be an alternative to axillary lymph node dissection in these patients. The aim was to undertake a systematic review and meta-analysis of the accuracy and reliability of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initial biopsy-proven node-positive breast cancer.

METHODS

A literature search was conducted using PubMed, Ovid MEDLINE, Embase and Web of Science databases up to 30 April 2017. Inclusion criteria for studies were pathological confirmation of initial node-positive disease, and sentinel lymph node biopsy performed after neoadjuvant chemotherapy followed by axillary lymph node dissection.

RESULTS

A total of 13 studies met the inclusion criteria and were included in the analysis (1921 patients in total). The pooled estimate of identification rate was 90 (95 per cent c.i. 87 to 93) per cent and the false-negative rate was 14 (11 to 17) per cent. In subgroup analysis, the false-negative rate with use of dual mapping was 11 (6 to 15) per cent, compared with 19 (11 to 27) per cent with single mapping. The false-negative rate was 20 (13 to 27) per cent when one node was removed, 12 (5 to 19) per cent with two nodes removed and 4 (0 to 9) per cent with removal of three or more nodes.

CONCLUSION

Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with biopsy-proven node-positive breast cancer is accurate and reliable, but requires careful patient selection and optimal surgical techniques.

Detailed Lymph Node Sectioning of Papillary Thyroid Carcinoma Specimen Increases the Number of pN1a Patients

Papillary thyroid carcinoma (PTC) is a common endocrine malignancy, frequently presenting with lymph node metastasis at the time of diagnosis. Lymph node staging (N) partly determines treatment, follow-up, and prognosis. Since 2011, our institution has employed a more comprehensive histopathological work-up of lymph nodes in patients with PTC. We sought to retrospectively determine the value of serial lymph node level sectioning in PTCs with negative preoperative lymph node status (pN0) as a method to increase the sensitivity of detecting metastatic disease. We included all patients that underwent thyroidectomy and central neck dissection and subsequent comprehensive lymph node level sectioning due to PTC with an initial pN0 status between the years 2011 and 2015 at our institution. Sixty-seven cases of PTC with a median of 10 metastatic free lymph nodes identified per case were included. After serial lymph node sectioning of the central compartment, 11 cases (16 %) revealed lymph node metastasis, six of which (55 %) presented with a small primary tumor (<20 mm, T1). Of all T1 tumors with initial pN0 status, 18 % (T1a) and 9 % (T1b) reached a pN1 stage after comprehensive lymph node sectioning. Cases with altered lymph node status had a median of 15 identified lymph nodes as compared to ten in cases that remained negative. We conclude that comprehensive lymph node sectioning increased the sensitivity of detecting metastases in PTC and altered the pathological TNM staging (pTNM) for a significant number of patients. Although of limited prognostic significance, the method should be considered as an adjunct tool when assessing lymph node status of PTC as a part of the routine histological work-up to ensure an accurate cancer staging.

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.

Efficacy and feasibility of the immunomagnetic separation based diagnosis for detecting sentinel lymph node metastasis from breast cancer

A purpose of this study was to establish a novel molecular diagnostic model and provide new insight into the intraoperative evaluation of the sentinel lymph node (SLN) metastasis in breast cancer. A total of 124 breast cancer patients who met the criteria of sentinel lymph node biopsy (SLNB) and underwent intraoperative biopsy were consecutively enrolled in this study. After the SLNs obtained from each patient were labeled, MOC-31 monoclonal antibody-mediated immunomagnetic separation (IMS) and flow cytometry were used to determine the expressions of breast cancer metastasis-related markers, including Mucin 1 (MUC1), CD44v6, and HER2. Alternatively, conventional intraoperative hematoxylin and eosin (HE) staining and cytokeratin immunohistochemistry (CK-IHC) were performed to detect potential SLN metastasis. The sensitivity, specificity, and false-negative rate of the three intraoperative diagnostic methods were compared and analyzed. A total of 55 positive-SLNs were found in 38 breast cancer patients using IMS, yielding a sensitivity of 86.4% (38/44), specificity of 94.7% (36/38), accuracy of 93.5% (116/124), false-positive rate of 2.5% (2/80), false-negative rate of 13.6% (6/44), positive predictive value of 95.5% (42/44), and negative predictive value of 93.0% (80/86). Patients with high expressions of CD44v6, MUC1, and HER2 in SLNs tended to have higher number of positive lymph nodes, among which the MUC1 and HER2 showed significant differences (P<0.05). Therefore, compared with conventional HE staining and CK-IHC, IMS technology has remarkably higher sensitivity and specificity and relative lower false-negative rate, thus making it an effective and feasible intraoperative detection method of SLN for breast cancer diagnosis to some extent.

Histologic evaluation of sentinel and non-sentinel axillary lymph nodes in breast cancer by multilevel sectioning and predictors of non-sentinel metastasis

Sentinel lymph node (SLN) provides accurate nodal staging for breast cancer. This technique has been introduced in Siriraj Hospital since 1998. The goal of this study is to assess its accuracy in predicting the state of the axilla, and compare the results of standard examination and multilevel sectioning. A retrospective analysis of 195 breast cancer patients who underwent both SLN biopsy (using dye alone as the lymphatic mapping) and axillary node dissection during 1998-2002 were analyzed. All slides including SLNs and the non-SLNs (NSLNs) were reviewed and multilevel study was performed on all SLNs and NSLNs [four levels of hematoxylin-eosin (HE) at 200 µm interval and keratin stains on the first and fourth levels]. Of 195 patients, 30% of cases were SLN-positive (32 NSLN-positive and 27 NSLN-negative). Additional study could detect positive axillary nodes 10.8% (4 SLN-positive and 5 NSLN-positive) more than standard HE stain. The false negative rate increased from 20.3% to 24.1%. The concordance between SLN and NSLN statuses was 89.7%. The sensitivity was 75.9%. By multivariate analysis, the significant predictors for axillary node metastasis were tumor size of more than 2.2 cm, histologic type of invasive ductal carcinoma (IDC), not otherwise specified (NOS) and lymphovascular invasion (LVI). By univariable analysis, the significant predictors of NSLN metastasis after positive-SLN were outer location of the tumor, LVI and perinodal extension. In conclusion, use of multilevel and immunohistochemistry increased detection of positive-SLNs. Caution should be kept in accepting SLN biopsy using peritumoral dye technique alone as the procedure for staging due to a high false-negative rate. The concordance rate of 89.7% confirmed the reliability of SLN. Outer location of tumor, LVI and perinodal extension is significant predictors of positive-NSLN after positive-SLN.

Treatment of sentinel node-positive breast cancer

Sentinel node biopsy has become well accepted as a minimally invasive means of accurately staging the axilla in breast cancer patients. Patients with metastases in the sentinel node(s) have traditionally proceeded to completion of axillary node dissection, whereas patients who are node negative can be spared the morbidity of this procedure. Recently, there has been some debate as to what constitutes node-positive disease and whether patients with metastasis in the sentinel node(s) require completion axillary dissection. This review addresses the controversies regarding the management of sentinel node-positive breast cancer patients.

Sentinel lymph node biopsy for breast cancer: from investigational procedure to standard practice

Sentinel lymph node biopsy, popularized in melanoma, has revolutionized the management of breast cancer. While the morbidity associated with axillary node dissection was once thought to be a requisite risk in order to appropriately stage the axilla, large validation studies have demonstrated that sentinel lymph node biopsy is a minimally invasive technique that can accurately predict nodal status. This technique has become an accepted practice in many centers, but there remain many controversies surrounding the technique itself, the pathologic evaluation of the sentinel node and the optimal management of patients with minimal nodal disease. The historic roots of this technique are discussed, along with the controversial issues surrounding the technique and the clinical trials that are currently ongoing.

The false-negative rate of sentinel node biopsy in patients with breast cancer: a meta-analysis

BACKGROUND

In sentinel node surgery for breast cancer, procedural accuracy is assessed by calculating the false-negative rate. It is important to measure this since there are potential adverse outcomes from missing node metastases. We performed a meta-analysis of published data to assess which method has achieved the lowest false-negative rate.

METHODS

We found 3,588 articles concerning sentinel nodes and breast cancer published from 1993 through mid-2011; 183 articles met our inclusion criteria. The studies described in these 183 articles included a total of 9,306 patients. We grouped the studies by injection material and injection location. The false-negative rates were analyzed according to these groupings and also by the year in which the articles were published.

RESULTS

There was significant variation related to injection material. The use of blue dye alone was associated with the highest false-negative rate. Inclusion of a radioactive tracer along with blue dye resulted in a significantly lower false-negative rate. Although there were variations in the false-negative rate according to injection location, none were significant.

CONCLUSIONS

The use of blue dye should be accompanied by a radioactive tracer to achieve a significantly lower false-negative rate. Location of injection did not have a significant impact on the false-negative rate. Given the limitations of acquiring appropriate data, the false-negative rate should not be used as a metric for training or quality control.

The sensitivity and specificity of sentinel lymph node biopsy for breast cancer at Baylor University Medical Center at Dallas: a retrospective review of 488 cases

Sentinel lymph node (SLN) biopsy has become the standard of care for breast carcinoma management, as it precludes the negative morbid effects-including decreased shoulder range of motion, lymphedema, and paresthesias-of unnecessary axillary lymph node dissection. However, the method of pathologic evaluation of the lymph node has been scrutinized to obtain the greatest sensitivity, specificity, and negative predictive value, ultimately for the benefit of the patient. This retrospective study analyzed 488 biopsies completed by two surgeons and read by multiple pathologists affiliated with Pathologists Biomedical Laboratories. When metastatic disease was not grossly obvious, analysis of the SLN began with touch imprint cytology and, if necessary, a frozen section analysis. On the subsequent day, three levels of the SLN were analyzed with hematoxylin and eosin stain and immunohistochemistry with cytokeratin AE1-3 and the appropriate control. Touch imprint cytology and/or frozen section analysis (where applicable) correctly identified 78 of 89 macrometastases, with a sensitivity of 88%, specificity of 100%, and negative predictive value of 97%. Sensitivity was 72% for micrometastases and 60% for isolated tumor cells, each with 100% specificity. In conclusion, the sensitivity and specificity of SLN biopsy at our institution compares with the higher end of percentages reported in the literature.

Sentinel node biopsy for breast cancer patients: issues for discussion and our practice

Sentinel node biopsy has been established for several years now as a standard procedure of breast cancer surgery, but there are several variations of the indications and the technique used. This paper provides information regarding several issues of debate for its application as are the selection criteria, the application to patients with multifocal/multicentric breast cancer or DCIS, postneoadjuvant chemotherapy, the necessary number of nodes to be biopsied, the need for lymphoscintigraphy, the technique for frozen section, the factors that may predict nonsentinel nodes (NSNs) involvement, the value of micrometastasis and isolated tumour cells, the internal mammary chain sentinel nodes, and finally the axillary recurrence after SLNB. Our view for these issues is included together with our experience of 430 SLNBs.

Patterns of enlarged lymph nodes in patients with metastatic renal cell carcinoma

OBJECTIVE

We reviewed the imaging studies of patients with known metastatic renal cell carcinoma (RCC) in order to more accurately assess where retroperitoneal lymphadenopathy occurs.

METHODS

The database of patients with metastatic RCC was reviewed and 101 patients were found from 2002 to 2006. Each patient's CT scans were then reviewed. Twenty-seven retroperitoneal sections were defined for each patient, with 3 positions in each of the x-, y-, and z-axis. Lymph nodes greater than 1 cm were then counted for each section.

RESULTS

Of the 101 patients, 31, of whom 28 qualified, were found to have retroperitoneal lymphadenopathy of a least 1 cm or greater. Two-thirds of nodes (87 out of 124) exhibited a suprahilar, intra-aortocaval, and retro-aortocaval trend of lymph node enlargement. Three patients (11%) had isolated infrahilar nodes, while 8 patients (29%) exhibited a skip lesion pattern by imaging criteria. Only 4 patients (14%) were noted to have lymph nodes that were confined to the ipsilateral (paraaortic or paracaval) nodes in the perihilar and infrahilar region, which would be readily accessible during renal surgery.

CONCLUSIONS

Lymphatic drainage in RCC is ill-defined, likely due to multiple lymphatic outflow channels. However, after a review of retroperitoneal lymphadenopathy imaging in patients with known metastatic RCC, there does seem to be a cephalad, posterior, and medial drainage pattern.

The evolution of lymph node assessment in breast cancer

Lymph node evaluation remains integral in the management of breast cancer for prognostic and therapeutic purposes. The introduction of sentinel lymph node biopsy has revolutionized axillary surgery, presenting new challenges relating to clinical implications and quality which will be reviewed in this article.

Novel intraoperative molecular test for sentinel lymph node metastases in patients with early-stage breast cancer

PURPOSE

An accurate, intraoperative sentinel lymph node (SLN) test could decrease delayed axillary dissections. Molecular tests may be more sensitive than current intraoperative tests but historically have not been rapid enough and have not been properly validated. We present the results from a large, prospective evaluation of the first rapid molecular SLN test, the Breast Lymph Node (BLN) Assay.

METHODS

A beta trial (n = 304) to determine the threshold levels of mammaglobin and cytokeratin 19 correlating with metastasis greater than 0.2 mm and a validation trial (n = 416) to validate the threshold cutoffs were conducted. Alternating portions from each SLN were processed for histology and the BLN Assay.

RESULTS

BLN Assay performance against extensive permanent-section histology verified by central pathology review was similar to that expected of standard permanent-section histology: sensitivity, 87.6%; specificity, 94.2%; positive predictive value, 86.2%; and negative predictive value (NPV), 94.9%. In 319 patients with both frozen-section hematoxylin and eosin results and BLN Assay results, the BLN Assay had higher sensitivity (95.6%) and NPV (98.2%) than frozen section (sensitivity, 85.6%; NPV, 94.5%). The assay can be performed in approximately 36 to 46 minutes for one to three nodes.

CONCLUSION

The BLN Assay allows a rapid evaluation of 50% of each SLN. Comparison with permanent-section histology on adjacent node pieces evaluated by expert pathologists indicated that the BLN Assay was more sensitive than current intraoperative techniques while maintaining high specificity. These data indicate that the assay may be clinically useful for intraoperative or postoperative axillary lymph node dissection decisions.

Recent advances and current controversies in the management of DCIS of the breast

Ductal carcinoma in situ (DCIS) is commonly diagnosed today, mainly due to widespread use of screening mammography. Despite a better understanding of its biological behavior, many issues regarding its optimal management remain controversial. The biological behavior of DCIS has been associated with distinct molecular and histological features (such as expression of COX2, Ki67, c-erbB2, p53 mutation, presence or absence of comedonecrosis, nuclear grade, hormone receptor status, etc.). Recent advances in the diagnosis of DCIS include using magnetic resonance imaging, and the use of stereotactic-guided directional vacuum-assisted biopsy (DVAB). Ductoscopy and ductal lavage have a limited role in the management of DCIS. Surgical treatment of DCIS includes simple local excision to various forms of wider excision (segmental resection or quadrantectomy), or even mastectomy (either simple or skin-sparing). Radiotherapy following breast-conserving surgery significantly reduces local recurrence rates. Axillary lymph node dissection is not required for the management of DCIS; however, during the last decade, sentinel lymph node biopsy is increasingly used to exclude the presence of axillary metastases (when invasive disease is present within the DCIS). This approach has many advantages (including the avoidance of a second surgery if invasive disease is diagnosed within the DCIS) and should be considered when there is an increased probability for the presence of invasive breast cancer within the DCIS. The role of other minimally invasive methods (such as the "therapeutic" application of the DVAB technique, radiofrequency ablation, laser therapy, cryotherapy and brachytherapy) in the management of small DCIS remains unproven. Tamoxifen should be considered in the management of selected patients with DCIS, such as patients with hormone receptor positive DCIS, young patients, and patients without risk factors for potential side effects. Additionally, and controversial, there is evidence that aromatase inhibitors may be better than tamoxifen in the management of DCIS.

Functional analysis of individual cells and microenvironment of breast cancer-draining lymph nodes

The development of distant metastases is the major cause of death in breast cancer (BC). In many BC cases, metastases are present in patients with no metastasis-positive lymph nodes (LN). Hence, there is a need to improve prognosis by a better prediction of the nodal status and tumor spread. The current study is designed to develop and utilize new functional characteristics of the cells and microenvironment of BC-draining LN, which may help to improve the estimation of LN metastatic involvement. Innovative devices and methodologies were developed for collecting, transferring, and analyzing LN at an individual-cell resolution. Using these devices, a suspension of living cells were prepared from the LN and processed for various assays, including immunophenotypic analysis, activation status, and invasion activity. The functional profile of tumor-activated LN cells showed an increase in the intracellular enzymatic reaction rate, accompanied by a homogeneous distribution of transferrin receptor as well as by a significant increase in matrix metalloproteinase proteolytic activity. Moreover, the proportion of cells exhibiting such a profile was significantly higher in tumor-containing LN than in tumor-free LN. Thus, the live and postfixation features of LN cells and their microenvironment, correlated with the functional status of the LN, may serve to improve their predictive value in breast cancer examination.

Promoter hypermethylation in sentinel lymph nodes as a marker for breast cancer recurrence

PURPOSE

Promoter methylation of tumor suppressor genes in histologically negative sentinel lymph nodes (HNSN) of early stage breast cancer patients has not been extensively studied. This study evaluates the methylation frequency and pattern in HNSN to determine if detection of hypermethylation of one or more genes is associated with an increased recurrence risk in node negative breast cancer.

EXPERIMENTAL DESIGN

In 1998, a prospective study of patients with early stage breast cancer and HNSN was initiated in order to correlate sentinel node analysis with clinical outcome. Nodal tissue was selected from 120 HNSN patients for methylation analysis in at least one and up to six sentinel nodes using a panel of nine genes. Corresponding primary breast tumors from 79 patients were also evaluated for hypermethylation. Methylation analysis was performed using nested Methylation Sensitive PCR (n-MSP). Logistical regression was used to evaluate the relationship between clinical recurrence and methylation status.

RESULTS

Over a median follow-up of 79 months, 13 of the 120 patients had clinical recurrence. Hypermethylation of genes was frequently observed in HNSN, but there was no correlation of methylation pattern and clinical recurrence. However, increased frequency of gene methylation of the primary tumor correlated with clinical recurrence.

CONCLUSIONS

Although hypermethylation of multiple genes occurs frequently in HNSN of breast cancer patients, it is not associated with breast cancer recurrence in the first 7 years of clinical follow-up.

Accuracy of pathologic examination in detection of complete response after chemoradiation for esophageal cancer

BACKGROUND

Although a substantial proportion of patients undergoing neoadjuvant chemoradiation for invasive esophageal cancer develop a pathologic complete response (pCR), these patients nonetheless have a poor 5-year survival rate. We hypothesized that routine pathologic examination fails to identify some residual cancer.

METHODS

Patients undergoing esophagectomy for cancer at 2 tertiary care centers were identified. Archived tumor blocks were retrieved for patients with pCR, sectioned at 50-mum intervals and reexamined for residual cancer.

RESULTS

Seventy patients underwent neoadjuvant chemoradiation. Tumor blocks were available for 23 of 26 complete responders. A total of 159 blocks were reexamined. One patient was found to have a possible focus of residual invasive adenocarcinoma versus high-grade dysplasia. The remaining 22 patients had no residual disease.

CONCLUSIONS

A more aggressive examination protocol for postchemoradiation esophagectomy specimens may not result in significant upstaging. Inadequate pathologic examination is likely not a major factor in the suboptimal survival in patients with pCR.

Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review

Ductal carcinoma in situ (DCIS) of the breast is defined as a proliferation of malignant epithelial cells within breast ducts without evidence of invasion through the basement membrane. The detection rate of DCIS of the breast has dramatically increased since the mid-1980s as the result of the widespread use of screening mammography. DCIS currently represents about 15-25% of all breast cancers detected in population screening programmes. Although inherently a non-invasive disease, occult invasion with the potential of lymph node metastases may occur. Where performing an axillary lymph node dissection-or-not for DCIS used to be an important dilemma, the same now holds for the sentinel node biopsy. This article reviews the potential role of the sentinel node biopsy (SNB) in patients with DCIS. We conclude that based on the current literature, there is in general no role for a SNB in DCIS. A SNB should only be considered in patients with an excisional biopsy diagnosis of high risk DCIS (grade III with palpable mass or large tumour area by imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS, although SNB may be contraindicated in many of the latter patients because of lesion size and/or multifocality. Even in these patients the value of a positive SN, containing mostly isolated tumour cells, is questionable.

TUMOUR SIZE AS A PREDICTOR OF AXILLARY NODE METASTASES IN PATIENTS WITH BREAST CANCER

BACKGROUND

The ability to predict the behaviour of breast cancer from its dimensions allows the clinician to inform a woman about the absolute benefits of adjuvant therapies or further surgery to control her disease. Tumour size and grade are independent predictors of nodal disease. This study aims to generate a tool, using Australian data, allowing surgeons to calculate the probability of axillary lymph node involvement in a preoperative setting.

METHODS

The histological reports of patients with breast cancer treated in 1995 in New South Wales were examined and tumour size, grade and nodal status recorded. Univariate and multivariate analyses identified predictors of node positivity and, using linear regression analysis, a simple formula to predict nodal involvement was derived.

RESULTS

In a 6-month period, 754 women had non-metastatic, unifocal breast cancer treated with surgery and complete axillary dissection and 283 (37.5%) had positive nodes. Tumour size remained an independent predictor of node positivity and the probability (%), y, of nodal involvement may be predicted by the formula y = 1.5 x tumour size (mm) + 7, r = 0.939 and P = 0.001.

CONCLUSIONS

This paper shows the need to assess the axilla in every patient because even patients with small tumours (0-5 mm) have the possibility of axillary involvement (7-14.5%). Use of this simple formula allows clinicians and patients to make informed decisions about the possible need for a full axillary dissection to reduce the chance of understaging and potentially undertreating a woman's breast cancer.

Application of Intraoperative Ultrasound to Nonsentinel Node Assessment in Primary Breast Cancer

PURPOSE

To evaluate whether intraoperative ultrasonography can help surgeons to identify patients with breast cancer and metastases confined to the sentinel node.

EXPERIMENTAL DESIGN

We used blue dye to identify sentinel node during 512 procedures done on 509 patients with breast cancers of <3 cm. After sentinel node biopsy, we used intraoperative ultrasonography to explore the whole axilla followed by at least level II axillary dissection. All sentinel nodes were evaluated histologically and immunohistochemically using anti-cytokeratin antibody. All nonsentinel nodes were examined by routine histology. Multiple logistic regression was used to assess the associations of interest and to adjust for potential confounders. Receiver operating characteristic curves were used to calculate the areas under the curves of interest and for comparisons.

RESULTS

Sentinel nodes were identified in 506 of 512 (98.8%) procedures and sentinel node metastases were found in 161 of these (31.8%). Subsequent axillary dissection revealed tumor involvement in nonsentinel nodes in 93 of 161 (57.8%) procedures. Multivariate analysis showed that tumor size, number of positive sentinel nodes, and metastatic size in sentinel nodes were independent factors predicting the presence of tumor-positive nonsentinel nodes. The validity of using either node size or cortical thickness ascertained by intraoperative ultrasound to predict nonsentinel node metastases was highly significant (P < 0.0001). Intraoperative ultrasound not only detected metastatic nonsentinel nodes in 89 of 93 (95.7%) cases but also detected metastatic nonsentinel nodes in patients with false-negative sentinel node mapping.

CONCLUSION

Sentinel node biopsy combined with intraoperative ultrasonography can help breast surgeons decide whether to perform a subsequent nonsentinel node dissection after identification of a positive sentinel node.

Comprehensive examination of sentinel lymph node in breast cancer: a solution without a problem?

Although several methods have been devised to examine sentinel lymph node (SLN) specimens in breast cancer, the extent of examination and whether it should routinely include multilevel sectioning to detect micrometastases (MM) (<2.0 mm) is still debated. In this study all "positive'' SLN biopsies from 67 consecutive patients with breast carcinoma and evaluated by means of an extended protocol were reviewed. Abnormal findings included micrometastases (MM) between 0.2 and 1.0 mm (14 cases), (MM) between 1.0 and 2.0 mm (8 cases), metastases>2.0 mm (22 cases), and isolated tumor cells (ITCs) (23 cases). The likelihood of finding metastatic deposits was comparable if sections were carried out at 100-, 150-, 200-, 250-, and 500-microm intervals. No metastatic foci>2.0 mm would have been missed. 1 MM (1.1 mm focus) was missed within the 250- and 500-microm levels on hematoxylin-eosin, but not complementary cytokeratin staining. Our data show that SLN step sectioning does not add significant yield if compared to standard examination carried on initial levels, if the minimal target of 1.0 mm micrometastatic deposit is sought.

Profile of immune cells in axillary lymph nodes predicts disease-free survival in breast cancer

BACKGROUND

While lymph node metastasis is among the strongest predictors of disease-free and overall survival for patients with breast cancer, the immunological nature of tumor-draining lymph nodes is often ignored, and may provide additional prognostic information on clinical outcome.

METHODS AND FINDINGS

We performed immunohistochemical analysis of 47 sentinel and 104 axillary (nonsentinel) nodes from 77 breast cancer patients with 5 y of follow-up to determine if alterations in CD4, CD8, and CD1a cell populations predict nodal metastasis or disease-free survival. Sentinel and axillary node CD4 and CD8 T cells were decreased in breast cancer patients compared to control nodes. CD1a dendritic cells were also diminished in sentinel and tumor-involved axillary nodes, but increased in tumor-free axillary nodes. Axillary node, but not sentinel node, CD4 T cell and dendritic cell populations were highly correlated with disease-free survival, independent of axillary metastasis. Immune profiling of ALN from a test set of 48 patients, applying CD4 T cell and CD1a dendritic cell population thresholds of CD4 > or = 7.0% and CD1a > or = 0.6%, determined from analysis of a learning set of 29 patients, provided significant risk stratification into favorable and unfavorable prognostic groups superior to clinicopathologic characteristics including tumor size, extent or size of nodal metastasis (CD4, p < 0.001 and CD1a, p < 0.001). Moreover, axillary node CD4 T cell and CD1a dendritic cell populations allowed more significant stratification of disease-free survival of patients with T1 (primary tumor size 2 cm or less) and T2 (5 cm or larger) tumors than all other patient characteristics. Finally, sentinel node immune profiles correlated primarily with the presence of infiltrating tumor cells, while axillary node immune profiles appeared largely independent of nodal metastases, raising the possibility that, within axillary lymph nodes, immune profile changes and nodal metastases represent independent processes.

CONCLUSION

These findings demonstrate that the immune profile of tumor-draining lymph nodes is of novel biologic and clinical importance for patients with early stage breast cancer.

Prediction of Metastasis to Non-sentinel Nodes by Sentinel Node Status and Primary Tumor Characteristics in Primary Breast Cancer in Taiwan

We aimed to determine how to approach the axilla after finding a positive sentinel node (SN) for a woman with breast cancer in Taiwan. We used blue dye staining to identify the SN in 824 procedures on 811 patients with breast cancer small than 3 cm by a single surgeon. All patients underwent SN biopsy, followed by at least level II axillary dissection. All SNs were evaluated histologically and immunohistochemically with anti-cytokeratin antibodies. Non-SNs were examined by routine histology. SNs were identified in 814/824 procedures (98.8%). SN metastases were found in 286/814 (35.1%). Subsequent axillary dissections revealed tumors in non-SNs in 188 (65.7%) of these patients. There was a relatively high incidence of non-SN metastases in our population. Tumor exhibiting high nuclear grading, ER-, PR-, Erb-2/neu overexpression, lymphovascular invasion, increasing tumor size, multiple positive SNs, and macrometastatic size in SNs (> 2 mm) were all significantly correlated with non-SN metastases. Multivariate analysis showed that tumor size, the number of positive SNs, and the metastatic size in SNs were independent factors predicting the presence of positive non-SNs. Small (< 2 cm) cancers, having only micrometastatic foci in the SN and having only one SN involved are closely correlated with the tumor-free non-SNs. Our data will assist such patients regarding the need for axillary dissection after finding a positive SN.

Clinical outcome of patients with lymph node-negative breast carcinoma who have sentinel lymph node micrometastases detected by immunohistochemistry

BACKGROUND

The ideal pathologic assessment of sentinel lymph nodes (SLNs) in patients with breast carcinoma remains controversial. The authors evaluated how detailed assessment of SLNs using immunohistochemistry (IHC) and serial sectioning would affect treatment decisions and outcomes in patients with breast carcinoma who had negative SLNs on standard hematoxylin and eosin staining.

METHODS

The SLNs from patients who were treated between June 1998 and June, 1999 and who had negative lymph node status determined by hematoxylin and eosin staining (n = 84 patients) were evaluated further with serial sectioning and cytokeratin IHC. Patients were offered adjuvant therapy based on primary tumor factors.

RESULTS

The median patient age was 57 years, and the median tumor size was 1.2 cm. At a median follow-up of 40.2 months, 81 patients (96%) were alive with no evidence of disease, 1 patient was alive with disease, 1 patient had died of disease, and 1 patient had died of other causes. Fifteen patients (18%) had micrometastases identified on IHC. Of the total 84 patients, information regarding adjuvant therapy was not available for 5 patients. Of the remaining 79 patients, 10 patients (13%) were not offered adjuvant chemotherapy but had positive SLN status determined by IHC. SLN status based on IHC evaluation did not correlate with age (P = 0.077), tumor size (P = 0.717), grade (P = 0.148), estrogen receptor status (P = 1.000), or lymphovascular invasion (P = 0.274). Furthermore, IHC-detected positive SLN status did not correlate with distant metastasis (P = 0.372) or overall or distant metastasis-free survival (P = 0.543 and P = 0.540, respectively).

CONCLUSIONS

Although the finding of SLN micrometastases by IHC may change management in > 12% of patients, preliminary results suggested that such micrometastases do not affect outcomes significantly.

Sentinel lymph nodes and breast carcinoma: analysis of 70 cases by frozen section

BACKGROUND

The sentinal node biopsy (SNB) is a reliable method for determining the status of the regional lymph nodes in patients with breast cancer. SNB technology is evolving rapidly, but no standardization has yet been accomplished. The aim of this study is to discuss the accuracy of this procedure and the optimal method for identifying micrometastases.

METHODS

We collected data from 70 women with primary invasive breast carcinoma who underwent SNB for breast cancer. We examined two frozen sections levels from each half of each lymph node, as well as a cytology imprint before arriving at the frozen section diagnosis. Immunohistochemistry with pancytokeratin (AE1/AE3) was done on the paraffin sections. For the association between the lymph node size and the possibility of metastases, Student's t test was used and a P value of less than 0.05 was regarded as significant.

RESULTS

The number of patients with metastases in SNB was 19, from which 15 cases were correctly diagnosed in frozen sections/imprints and four cases were false negative. The axillary toilet from all cases with SNB metastases smaller than 2 mm showed no additional positive nodes. Lymph node diameter showed a significant association with sentinel node status (P<0.0001).

CONCLUSION

Frozen section examination of SNB from patients with breast carcinoma is both specific (100%) and sensitive (79%). Diagnosis of lobular carcinoma can be difficult, and may require immunohistochemistry with cytokeratin for diagnosis. Small metastases in a non-optimal frozen section may be difficult to discern. Cytology imprints add nothing to the diagnosis.

What is the best indicator to determine anatomic pathology workload? Canadian experience

Health care resources in Canada are limited, and there is tremendous pressure to reduce laboratory budgets. It is almost impossible to acquire new pathologist positions to adequately meet service demands. There is a need to determine objectively the appropriate pathologist workload. I looked at multiple indicators (total accessioned cases, number of specimens, slides, blocks, Royal College of Pathologists [London, England] model, population served, and level 4 equivalent [L4E]) that might reflect the pathologist's work and determine which indicators are the best. L4E is a calculated weighted value based on complexity levels of individual anatomic pathology consultation. Of all indicators analyzed, L4E is the best reflection of a pathologist's anatomic pathology work because it has the best statistical values, is a direct output measurement of pathologist consultations, and uses data routinely collected in many North American laboratories.

Sensitive, noninvasive detection of lymph node metastases

BACKGROUND

Many primary malignancies spread via lymphatic dissemination, and accurate staging therefore still relies on surgical exploration. The purpose of this study was to explore the possibility of semiautomated noninvasive nodal cancer staging using a nanoparticle-enhanced lymphotropic magnetic resonance imaging (LMRI) technique.

METHODS AND FINDINGS

We measured magnetic tissue parameters of cancer metastases and normal unmatched lymph nodes by noninvasive LMRI using a learning dataset consisting of 97 histologically proven nodes. We then prospectively tested the accuracy of these parameters against 216 histologically validated lymph nodes from 34 patients with primary cancers, in semiautomated fashion. We found unique magnetic tissue parameters that accurately distinguished metastatic from normal nodes with an overall sensitivity of 98% and specificity of 92%. The parameters could be applied to datasets in a semiautomated fashion and be used for three-dimensional reconstruction of complete nodal anatomy for different primary cancers.

CONCLUSION

These results suggest for the first time the feasibility of semiautomated nodal cancer staging by noninvasive imaging.