pathological evaluation of sentinel lymph node biopsy in breast cancer n.
Download
Skip this Video
Download Presentation
Pathological Evaluation of Sentinel Lymph Node Biopsy in Breast Cancer

Loading in 2 Seconds...

play fullscreen
1 / 38

Pathological Evaluation of Sentinel Lymph Node Biopsy in Breast Cancer - PowerPoint PPT Presentation


  • 152 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Pathological Evaluation of Sentinel Lymph Node Biopsy in Breast Cancer' - imaran


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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
  • 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
  • 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

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
  • 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
  • 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
  • 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

slide8

2 mm

2-3 mm

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

metastases
Metastases

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

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

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
  • 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
  • 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
slide30

H&E and Immunohistochemistry

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

slide31

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
  • 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
  • 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

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
  • 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
  • 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 is optional in routine patient management
  • Molecular analysis be restricted to research purposes as controversies over the interpretation and the lack of specific markers