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 node 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 node 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.

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Sentinel lymph node in endometrial cancer

International Journal of Gynecological Cancer ◽

10.1111/j.1525-1438.2007.00909.x ◽

2007 ◽

Vol 17 (5) ◽

pp. 1113-1117 ◽

Cited By ~ 48

Author(s):

L.A.F Lopes ◽

S. M Nicolau ◽

F. F Baracat ◽

E. C Baracat ◽

W. J Gonçalves ◽

...

Keyword(s):

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Nodes ◽

Sentinel Node ◽

Endometrial Carcinoma ◽

Frozen Section ◽

False Negative ◽

Pelvic Lymphadenectomy ◽

Clinical Staging ◽

Blue Dye

The aim of this study was to evaluate the possibility of identifying the sentinel lymph node and involvement of neoplastic cells in patients with endometrial carcinoma limited to the uterus, and also its correlation with the conditions of other pelvic and para-aortic lymph nodes. Forty patients with endometrial carcinoma, clinical staging I and II, were submitted to complete surgical staging through laparotomy, as recommended by FIGO in 1988. The sentinel node was investigated using patent blue dye in the myometrial subserosa. The sentinel node was excised and submitted to frozen section examination of specimen, stained with hematoxylin and eosin (H&E). Afterward, selective bilateral para-aortic and pelvic lymphadenectomy, total hysterectomy with bilateral salpingo-oophorectomy were performed. The lymph nodes excised were examined by means of paraffin-embedded slices stained with H&E and of imunohistochemistry with antikeratin antibody AE1/AE3. The sentinel lymph node was identified in 77.5% of patients (31/40), and 16.1% (5/31) presented neoplastic involvement in the node. In 25 cases of negative sentinel node, 96% (24/25) had no neoplastic involvement, and 4% (1/25) had other lymph node affected (false negative). In nine cases with no sentinel node identified, 55.5% (5/9) had lymph node involvement. The results of this study allow us to conclude that it is possible to identify the sentinel node using the methods described, and the pathologic examination significantly represents the same conditions of other pelvic and para-aortic lymph nodes.

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The importance of pre-operative axillary ultrasound and intra-operative sentinel lymph node frozen section analysis in patients with early breast cancer – a 3-year study

Annals of The Royal College of Surgeons of England ◽

10.1308/003588411x12851639108196 ◽

2011 ◽

Vol 93 (2) ◽

pp. 103-105 ◽

Cited By ~ 3

Author(s):

Melissa M Sanders ◽

Shamaela Waheed ◽

Sanjay Joshi ◽

Caroline Pogson ◽

Stephen R Ebbs

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Nodes ◽

Sentinel Node ◽

Axillary Dissection ◽

Frozen Section ◽

Axillary Ultrasound ◽

Node Biopsy ◽

Operative Ultrasound

INTRODUCTION To ensure appropriate axillary surgery is performed at a single operation, we have sought to identify patients with involved nodes who might progress directly to axillary dissection. PATIENTS AND METHODS We evaluated pre-operative ultrasound of the axilla and intra-operative frozen section of sentinel lymph nodes over a 3-year period. Patients with clinical early breast cancer underwent axillary ultrasound. Abnormal nodes were defined as a cortex > 2.5 mm, loss of high echogenic medulla, and morphological changes. Any axilla containing a lymph node considered abnormal had ultrasound-directed fine needle aspiration (FNA) performed. Patients with positive cytology proceeded directly to axillary dissection. Patients with negative cytology and those with normal ultrasound proceeded to sentinel four-node biopsy using Patent Blue dye alone. A single sentinel node was evaluated by intra-operative frozen section. RESULTS A total of 311 patients underwent pre-operative ultrasound successfully, identifying 115 (77%) patients of the total 150 who were found to have positive lymph nodes. Overall, 196 patients underwent sentinel lymph node biopsy analysis intra-operatively. Of the 11 false negative cases in which the lymph node was found to be positive postoperatively, eight cases showed the single tested sentinel node contained cancer that was recognised on postoperative staining but not frozen section. In six, the deposit in the sentinel node was a micrometastasis. Three cases were found to contain cancer in the ‘non-sentinel' node; in all, this was micrometastatic disease. CONCLUSIONS This study confirms the value of pre-operative ultrasound and intra-operative frozen section examination of axillary nodes. Only 3.5% of patients required two operations.

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Impact of sentinel lymph node frozen section evaluation to avoid combined treatment in early-stage cervical cancer

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-001113 ◽

2020 ◽

Vol 30 (6) ◽

pp. 744-748 ◽

Cited By ~ 2

Author(s):

Lukas Dostalek ◽

Jiri Slama ◽

Daniela Fisherova ◽

Roman Kocian ◽

Anna Germanova ◽

...

Keyword(s):

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Nodes ◽

Predictive Value ◽

Radical Surgery ◽

Frozen Section ◽

Combined Treatment ◽

Lymph Node Involvement ◽

Sentinel Lymph Nodes ◽

Sensitivity Specificity

BackgroundThe need for radical surgery followed by adjuvant chemoradiation may be reduced by abandoning radical surgery in patients in whom lymph node involvement is detected intra-operatively.ObjectivesTo analyze, in a retrospective cohort study, the efficacy of the algorithm using intra-operative pathological assessment of sentinel lymph nodes.MethodsA retrospective single-institution study was carried out, which analyzed data from all consecutive patients with cervical cancer who were referred for primary surgical treatment between May 2005 and December 2015. Inclusion criteria were as follows: (1) TNM stage T1a1 with lymphovascular space invasion, T1a2, T1b, T2a, and selected T2b with incipient parametrial invasion; (2) adenocarcinoma, squamous cell carcinoma, or adenosquamous carcinoma; (3) no evidence of enlarged suspicious nodes or distant metastases on pre-operative imaging; (4) primary surgery with curative intent; (5) successful detection of sentinel lymph node, at least, unilaterally. All patients had at least one sentinel lymph node detected and submitted for frozen section evaluation. When sentinel lymph node involvement was detected intra-operatively, the cervical procedure was abandoned and the patient was referred for definitive chemoradiation. Radical surgery was completed in patients with intra-operative negative sentinel lymph nodes. The reliability of intra-operative sentinel lymph node assessment was evaluated by calculating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio.ResultsThe study included a total of 309 patients. Sentinel lymph nodes were detected bilaterally in 86% of the patients. Lymph node positivity was detected intra-operatively in 18 (6%) patients in whom the cervical procedure was abandoned. Adjuvant radiotherapy after completed radical surgery was given to 29 (9%) patients, including 20 patients with macrometastases (8) or micrometastases (12) reported from the final histology, eight patients with positive parametria (all ≤3 mm), and one patient with a positive vaginal resection margin. The sensitivity, specificity, positive predictive value, and negative predictive value for the intra-operative detection of lymph node positivity (macrometastases or micrometastases) was 47% (95% CI 31% to 64%), 100%, 100%, and 93% (95% CI 90% to 96%), respectively. A total of 18 (6%) patients were spared combined treatment owing to the intra-operative sentinel lymph node triage; 29 patients (9%) received combined treatment with both radical surgery and adjuvant radiotherapyConclusionsOf 47 patients with high-risk prognostic risk factors (lymph node, parametria, or surgical margin involvement), combined treatment was successfully avoided in 18 (38%). Despite an effort to triage the patients intra-operatively, 9% received a combination of cervical procedure and adjuvant chemoradiation, mostly owing to the low sensitivity of the frozen section in the detection of micrometastases and macrometastases.

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Intraoperative imprint cytology of sentinel lymph nodes in breast cancer patients: Comparation with frozen section

Vojnosanitetski pregled ◽

10.2298/vsp171120067i ◽

2020 ◽

Vol 77 (2) ◽

pp. 196-200

Author(s):

Tatjana Ivkovic-Kapicl ◽

Ferenc Vicko ◽

Milana Panjkovic ◽

Zoran Radovanovic ◽

Tijana Vasiljevic ◽

...

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Nodes ◽

Cancer Patients ◽

Frozen Section ◽

Sentinel Lymph Nodes ◽

Imprint Cytology ◽

Breast Cancer Patients ◽

Touch Imprint Cytology

Background/Aim. Sentinel lymph node (SLN) biopsy has been established as the standard of care for axillary staging in patients with invasive breast carcinoma and clinically negative lymph nodes. Intraoperative assessment of sentinel lymph nodes might be done by frozen section (FS), touch imprint cytology (TIC) and one step nucleic acid amplification. The aim of this study was to review our institution's results with SLN biopsy using TIC and FS technique as intraoperative diagnostic tool for breast cancer patients. Methods. SLNs from 101 patients were examined intraoperatively by frozen hematoxylin-eosin (H&E) stain and by touch imprint cytology. Results of TIC were compared with FS and permanent histology sections. Results. The total number of dissected SLNs was 163 with a mean of 1.6 (1?4) per patient. The permanent H&E identified 19 (19%) patients with a sentinel lymph node metastasis and 82 (81%) patients with tumor-free sentinel nodes. The sensitivity/ specificity rates were 73.7%/99.3%, respectively for TIC and 84.2%/100%, respectively for FS. Relevant positive/ negative predictive values were 93.3%/96.6%, respectively for TIC and 100%/97.9%, respectively for FS. Conclusion. Our experience with TIC and FS for the intraoperative evaluation of SLNs is similar to the findings from previously reported studies. We detected the high specificity for both methods, but TIC technique appeared to be less sensitive than FS in detecting SLN metastases in breast cancer patients. TIC could be recommended as reasonable alternative to frozen section due to its simplicity and low cost.

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Frozen Section for Detection of Lymph Nodes After Cervical Injection with Indocyanine Green (ICG) for Sentinel Lymph Node Technique in Endometrial Cancer Staging

Annals of Surgical Oncology ◽

10.1245/s10434-018-6698-9 ◽

2018 ◽

Vol 25 (12) ◽

pp. 3692-3698 ◽

Cited By ~ 9

Author(s):

Jvan Casarin ◽

Francesco Multinu ◽

Kalyan Pasupathy ◽

Amy Weaver ◽

Michaela McGree ◽

...

Keyword(s):

Endometrial Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Nodes ◽

Indocyanine Green ◽

Frozen Section ◽

Cancer Staging

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Can intraoperative ultrasound replace the frozen section in the assessment of ex vivo sentinel lymph node biopsy in early breast cancer in countries with limited resources?

Egyptian Journal of Radiology and Nuclear Medicine ◽

10.1186/s43055-021-00505-1 ◽

2021 ◽

Vol 52 (1) ◽

Author(s):

Rasha Wessam Abdel Rahman ◽

Emad Salaheldin Khallaf ◽

Lamia Adel Salaheldin ◽

Mohamed Nasr Hafez ◽

Mohannad Aly Fayed ◽

...

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Sentinel Lymph Node Biopsy ◽

Lymph Nodes ◽

Ex Vivo ◽

Frozen Section ◽

Lymph Node Biopsy ◽

Axillary Lymph ◽

Node Biopsy

Abstract Background Accurate staging and proper management of axillary lymph nodes (ALNs) in breast cancer patients are important for treatment. Surgical management of the axilla has evolved greatly in the last 20 years. Sentinel lymph node biopsy (SLNB), which was first investigated in the early 1990s, has replaced routine axillary lymph node dissection. This study evaluates the capability of using an ultrasound (US) as an alternative tool for the frozen section in the assessment of the ex vivo sentinel lymph node biopsy in countries with limited resources. Results The study is a prospective study that included 216 female patients with early breast cancer and negative axillary lymph nodes. All excised lymph nodes were examined by the intraoperative US and frozen section examinations. All the results were correlated with the final histopathological results. The number of negative nodes by US, frozen, and paraffin section examination was 58.30%, 69.40%, and 69.40%, respectively. The number of positive nodes by the US, frozen, and paraffin section examinations was 41.70%, 30.60%, and 30.60% respectively. The sensitivity, specificity, PPV, NPV, and accuracy of US in the detection of positive lymph nodes were 95.45%, 82%, 70%, 97.62%, and 86.11%, respectively, and the sensitivity, specificity, PPV, NPV, and accuracy of frozen examination in the detection of positive lymph nodes were 90.91%, 96%, 90.91%, 96%, and 94.44%, respectively. Conclusion Intraoperative US is a good negative test in the assessment of ex vivo SLNB, but it is not a good positive test, so it cannot replace the intraoperative frozen section in the assessment of SLNs.

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Novel Intraoperative Molecular Test for Sentinel Lymph Node Metastases in Patients With Early-Stage Breast Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2007.14.0665 ◽

2008 ◽

Vol 26 (20) ◽

pp. 3338-3345 ◽

Cited By ~ 63

Author(s):

Thomas B. Julian ◽

Peter Blumencranz ◽

Kenneth Deck ◽

Pat Whitworth ◽

Donald A. Berry ◽

...

Keyword(s):

Lymph Node ◽

Sentinel Lymph Node ◽

Predictive Value ◽

Early Stage ◽

Frozen Section ◽

High Specificity ◽

Cytokeratin 19 ◽

Axillary Lymph ◽

Molecular Tests ◽

Permanent Section

PurposeAn 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.MethodsA 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.ResultsBLN 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.ConclusionThe 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.

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BIOPSY OF THE SIGNALING LYMPH NODES IN GASTRIC CANCER - CURRENT STATUS OF THE PROBLEM AND PROSPECTS

Problems in oncology ◽

10.37469/0507-3758-2018-64-3-335-344 ◽

2018 ◽

Vol 64 (3) ◽

pp. 335-344

Author(s):

Aleksey Karachun ◽

Yuriy Pelipas ◽

Oleg Tkachenko ◽

D. Asadchaya

Keyword(s):

Gastric Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Nodes ◽

Stomach Cancer ◽

Current Status ◽

Regional Lymph Nodes ◽

Systematic Analysis ◽

Tumor Spread ◽

Special Value

The concept of biopsy of sentinel lymph node as the first lymph node in the pathway of lymphogenous tumor spread has been actively discussed over the past decades and has already taken its rightful place in breast and melanoma surgery. The goal of this method is to exclude vain lymphadenectomy in patients without solid tumor metastases in regional lymph nodes. In the era of minimally invasive and organ-saving operations interventions it seems obvious an idea to introduce a biopsy of sentinel lymph node in surgery of early gastric cancer. Meanwhile the complexity of lymphatic system of the stomach and the presence of so-called skip metastases are factors limiting the introduction of a biopsy of sentinel lymph node in stomach cancer. This article presents a systematic analysis of biopsy technology of signaling lymph node as well as its safety and oncological adequacy. Based on literature data it seems to us that the special value of biopsy of sentinel lymph nodes in the future will be in the selection of personalized surgical tactics for stomach cancer.

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Cytologic Features of Lipogranulomatous Reaction in an Axillary Sentinel Lymph Node

Acta Cytologica ◽

10.1159/000513982 ◽

2021 ◽

pp. 1-4

Author(s):

Jose Antonio Jimenez-Heffernan ◽

Mariel Valdivia-Mazeyra ◽

Patricia Muñoz-Hernández ◽

Consuelo López-Elzaurdia

Keyword(s):

Lymph Node ◽

Sentinel Lymph Node ◽

Sentinel Lymph Node Biopsy ◽

Lymph Nodes ◽

Breast Biopsy ◽

Lymph Node Biopsy ◽

Sentinel Lymph Nodes ◽

Fat Necrosis ◽

Histologic Analysis ◽

Node Biopsy

Introduction: Multinucleated giant cells (MGC) are a rare finding when evaluating axillary sentinel lymph nodes. Some are described as foreign body-type MGC accompanied by foamy macrophages. They have been rarely reported in nodes from patients in which a previous breast biopsy was performed. The tissue damage induced by biopsy results in secondary changes including fat necrosis and hemorrhage that can migrate to axillary nodes. In this report, we illustrate a lipogranulomatous reaction in cytologic samples obtained during a sentinel lymph node examination of a woman previously biopsied because of breast carcinoma. We have found no previous cytologic descriptions and consider it an interesting finding that should be known to avoid diagnostic misinterpretations. Case: A 51-year-old woman underwent mastectomy of the right breast with a sentinel lymph node biopsy at our medical center. One month before, a control mammography revealed suspicious microcalcifications and a vacuum-assisted breast biopsy resulted in a diagnosis of high-grade intraductal carcinoma with comedonecrosis. Surgery with a sentinel lymph node biopsy was performed. The sentinel node was processed as an intraoperative consultation. Frozen sections and air-dried Diff-Quik stained samples were obtained. They showed abundant lymphocytes with MGC and tumoral cells. MGC showed ample cytoplasm with evident vacuoles of variable size. Occasional hemosiderin-laden macrophages were also present. The complete histologic analysis and immunohistochemical studies revealed no malignant cells. Histologic analysis showed, in subcapsular location, occasional MGC phagocyting lipid droplets. Hemosiderin-laden macrophages were a common finding. Conclusion: Lipogranulomas may appear at axillary sentinel lymph nodes because of fat necrosis induced by previous breast biopsy. The most important consideration is not confounding MGC with epithelial cell clusters. This can occur with not well-processed samples, especially if unmounted.

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