Intraoperative Sentinel Node Imprint Cytology

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Intraoperative Sentinel Node Imprint Cytology
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Background

• Breast cancer screening has resulted in cancers
  being detected at an earlier stage
• The proportion of patients with positive nodes at
  diagnosis has also fallen in the last 30 years
  from 45 to 31
• Axillary dissection is associated with morbidity,
  most significantly lymphoedema
• Reported rates of lymphoedema vary widely (0-58)

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The axilla

• NSABP B-04 (pre-screening era) showed that
  clinically node-negative patients had no
  difference in survival whether they underwent
  axillary clearance or axillary radiation
• However, the axilla was the first site of
  recurrence in 21 of irradiated patients
• 39 of patients in the radical mastectomy arm
  were clinically node-negative had positive nodes
• Axillary dissection provides the best means of
  controlling local recurrence

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Sentinel node biopsy

• The first lymph node in the drainage of the
  breast and presumably the first to be involved in
  any regional spread
• Meta-analysis by Miltenburg et al (912 cases)
• A node can be identified in up to 97 of cases
  and biopsy predicts axillary status in 97
• False negative rate is about 5
• Rate of positive nodes was 33

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Imprint cytology why bother?

• Histological examination of the sentinel node
  takes time, therefore the patient will need to
  undergo further surgery at another date if
  positive
• Frozen section is associated with tissue loss and
  a significant false-negative rate

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Bochner et al (Adelaide, 2003)

• Diff-Quik used on 53 patients
• Sensitivity 60
• IIC 47 false ves, 0 false ves
• 7/8 false ves were due to micrometastases
• 3/7 found on HE
• 4/7 found on IHC
• Last case due to lobular carcinoma
• Result time 25 minutes (median)

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Karamlou et al (Portland, 2003)

• 142 IICs
• 67 ductal, 25 lobular
• Staining method for IIC not given
• Sensitivity 75.3
• False negative rate 4.9
• No false positives

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Aihara (2003)

• TIC TIHC
• Pap stain, anti-cytokeratin antibody
• 49/205 nodes were ve
• Sn TIC 84, TIHC 86, combined 88
• Combined false ves rate 15 of patients (6/40)
• Histo false ve rate 1/78 (1.2) due to
  extra-capsular micrometastases

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Lee et al (Texas, 2002)

• 65 cases
• gt90 stained with Diff-quik, rest with Pap.
• Sensitivity of 65
• False negative rate 9
• One false negative HE

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Shiver et al (2002)

• Diff-Quik
• Sensitivity 56
• False negative rate 12

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Motomura (2000)

• Frozen section and imprint cytology (Pap. stain)
• 153 sentinel nodes
• Sensitivity 96
• Cytology 24/25 true ves, 7/76 false ves
• Frozen section 13/25 true ves, 0 false ves
• Micrometastases found on IHC of 8 nodes which
  were ve on cytology but ve on HE

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Ratanawichitrasin (1999)

• 60 cases with SN biopsy axillary dissection
• IIC alcohol fixed, stained with HE
• Sensitivity 98
• False negative rate 2.4
• 2 falsely negative SNs

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Creager et al (2004)

• Subgroup analysis of previously report series of
  678 consecutive patients, with reference to
  lobular carcinoma (LC)
• 61 cases of pure LC
• Accuracy was 82
• 11/23 falsely negative

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Salem et al (2002)

• Evaluation study of IHC for IIC
• 344 axillary LNs (not sentinel) with imprint
  cytology immunohistochemistry (anticytokeratin
  19)
• Sensitivity 100
• Result within 45 minutes
• Need an experienced cytologist