Pathological evaluation of sentinel lymph node biopsy in breast cancer
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Pathological Evaluation of Sentinel Lymph Node Biopsy in Breast Cancer. N. Krishnani. Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow. These PowerPoint presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

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Pathological evaluation of sentinel lymph node biopsy in breast cancer
Pathological Evaluation of Sentinel Lymph Node Biopsy in Breast Cancer

N. Krishnani

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow

These PowerPoint presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.


Sentinel lymph node
Sentinel Lymph Node Breast Cancer

  • First node to which lymph drainage and metastasis from breast cancer occurs

  • Central group of level I (most common)

  • Level II or III

  • Intramammary

  • Interpectoral or internal mammary node

Proceedings of the Consensus Conference on Role of SLNB, 2001 Philadelphia


Sentinel lymph node1
Sentinel Lymph Node Breast Cancer

  • Represent the entire nodal basin

  • Most likely to contain tumor if metastasis has occurred

  • If sentinel nodes are patholgically benign, all of the other axillary nodes can be considered tumor free

  • SLNB is suitable replacement for axillary dissection as a staging and diagnostic procedure in T1 andT2 breast cancers


Sentinel lymph node2
Sentinel Lymph Node Breast Cancer

Approximately 40% of operable breast cancer have axillary disease according to conventional histological methods

  • Stage Positive SLN

  • T1a 4.3%

  • T1b 19.5%

  • T1c 23.8%

  • T2 48.9%

  • T3 66.7%


Inclusion and exclusion criteria
Inclusion and Exclusion Criteria Breast Cancer

  • Stage T1 or T2 disease without palpable nodal metastases

  • Palpable axillary node metastases

  • Multifocal breast cancer

  • Pregnancy or currently breast feeding

  • Prior major breast or axillary operations

  • Allergies to blue dye or radiocolloid

Proceedings of the Consensus Conference on Role of SLNB, 2001 Philadelphia


Sentinel node biopsy in ductal carcinoma in situ
Sentinel Node Biopsy in Ductal Carcinoma In-situ Breast Cancer

  • Not indicated in mammographically detected DCIS or incidental finding.

  • Indications:

  • Palpable mass

  • Large areas of calcification

  • large lumpectomy

  • High grade with or without comedo necrosis

  • (microinvasion may be overlooked because of the area of disease is so large)


Handling of specimen
Handling of Specimen Breast Cancer

  • Measured and cut along its longitudinal axis into 2 mm-thick sections

  • Gross examination to detect focal lesions

  • Each 2 mm thick sections be cut at three levels

  • Imprint cytology smears are prepared

  • Remaining lymph node sections are then submitted for paraffin section histology

  • Each paraffin block should be sectioned at 3 levels

  • Report include individual cell / colonies / large size and location of malignant cells

Proceedings of the Consensus Conference on Role of SLNB, 2001 Philadelphia


2 mm Breast Cancer

2-3 mm

Am J Surg Pathol 2003;27(3):385-389



Metastases
Metastases Breast Cancer

Macrometastases: Any tumor deposit > 2mm

Micrometastases: Cohesive cluster of malignant cells, 0.2 mm and upto and including 2.0 mm in diameter. Indicate residual disease in approx. 10% of patients

Sub-micrometastases: Clusters of malignant cells measuring less than 0.2 mm. Seen by IHC

No clinical significance and highly unlikely to be associated with significant residual metastasis and predict an adverse outcome


Frozen section
Frozen Section Breast Cancer

Advantages

Interpretation of nodal architecture available

More specific diagnosis possible

Size of metastatic focus measurable

Can be complemented by rapid IHC

Histologists are more familiar with the method

Disadvantages

Relatively time-consuming

More expensive

Freezing artifacts

Some tissue is lost

More expensive


Imprint cytology
Imprint Cytology Breast Cancer

Advantages

Simple / cheap / rapid

Interpretation of cytological / nuclear details available

Avoid tissue loss

Can be complemented by IHC

Disadvantages

Size and area of metastatic focus not detectable

More indeterminate / deferred diagnoses

Need special training to interpret

Can not differentiate between micro and macrometastases





Intraoperative cytology
Intraoperative Cytology Breast Cancer

  • Diagnostic accuracy did not exceed that of frozen section

  • Occasional false positive case

  • Concordance rate is approx. 90%

  • When both method employed, diagnostic accuracy improve

Takeshi Nagashima et al, Acta Cytol 2003;47:1028-1032


Immunohistochemical technique
Immunohistochemical Technique Breast Cancer

  • More accurate and used as adjunct to routine stain

  • Antibody to cytokeratin used to detect small focus of malignant cells (Micrometastases or isolated tumor cells)

  • False positive

  • Benign transport of breast epithelium

  • Degenerating cells in transit

  • Dendritic cells

  • Macrophages

  • Epidermal squamous cells



H&E and Immunohistochemistry Breast Cancer

Probability of non-SLN metastasis will be less than 0.1% if SLN negativity is confirmed by both H&E and immunohistochemistry

Turner et al: Am J Surg Pathol 1999;23:263-267


Implications of Micrometastases Seen Only on Immunohistochemistry

  • What is the significance of occult metastases in terms of prognosis

  • What is the significance of occult metastases in terms of predicting further nodal involvement (approx. 12%)

  • Do these patient stand to benefit from completion axillary lymph node dissection and / or systemic chemotherapy


Implications of micrometastasies seen only on immunohistochemistry
Implications of Micrometastasies Seen Only on Immunohistochemistry

  • Data are inconclusive at this time

  • Additional studies are needed in order to establish the role of IHC detected lymph node metastases


Recommendations
Recommendations Immunohistochemistry

  • Ignore the presence of isolated tumor cells

  • Either refrain from examining SLN by IHC or address on case by case basis

  • Allweis et al, Breast 2003;12:163-167 and European Consensus group for Breast Screening Pathology


Recommendations1
Recommendations Immunohistochemistry

  • Standard practice and, the pathology report should state only whether metastasis are found on H&E stained slide

  • IHC may be performed when the H&E stained slides have suspicious cells that are equivocal

  • Cytokeratin positive malignant cells be quantified

  • Proceedings of the Consensus Conference on Role of SLNB, 2001 Philadelphia


Recommendations2
Recommendations Immunohistochemistry

Adjuvant therapy, either chemotherapy or hormonal treatment (or for completion axillary dissection or axillary radiation) should not be made solely on the basis of information obtained by IHC of sentinel lymph node

Proceedings of the Consensus Conference on Role of SLNB, 2001 Philadelphia


Molecular analysis
Molecular Analysis Immunohistochemistry

  • Assesment by reverse transcription-polymerase chain reaction (RT-PCR)

  • More sensitive than immunohistochemistry

  • Specific markers are lacking, and false negative tests

  • Relevance is even more debatable than occult metastasis detected by immunohistochemistry

  • Results are highly variable and high rate of upstaging (14-50%)

  • Experimental assessment

  • Not feasible in all pathology lab


Summary of consensus
Summary of Consensus Immunohistochemistry

  • Intraoperative assessment of SNs is strongly recommended

  • Careful handling specimen and cut node into 2 mm section and examine for any focal lesion

  • Step sectioning or multiple level assessment should be used, although the optimal distance between these step is controversial

  • Choice of method should be institutional depending on the resources

  • Imprint cytology should be done in conjunction with frozen section


Summary of consensus1
Summary of Consensus Immunohistochemistry

  • Immunohistochemistry is optional in routine patient management

  • Molecular analysis be restricted to research purposes as controversies over the interpretation and the lack of specific markers


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