Indian Journal of Surgery

, Volume 77, Supplement 2, pp 335–340

Intraoperative Frozen Section Evaluation of Sentinel Lymph Nodes in Breast Carcinoma: Single-Institution Indian Experience

  • S. P. Somashekhar
  • Zahoor Ahmed Naikoo
  • Shabber S. Zaveri
  • Soumya Holla
  • Suresh Chandra
  • Suniti Mishra
  • R. V. Parameswaran
Original Article

Abstract

Sentinel lymph node biopsy is an established way of predicting axillary nodal metastasis in early breast cancer. Intraoperative frozen sections (FS) of sentinel lymph nodes (SLNs) can be used to detect metastatic disease, allowing immediate axillary lymph node dissection. The purpose of this study was to evaluate the accuracy of intraoperative frozen sections in evaluation of sentinel lymph nodes in cases of breast cancer. Between March 2006 and August 2010, a total of 164 patients with clinically node-negative operable breast cancer were subjected to sentinel lymph node biopsy of axillary lymph nodes using preoperative peritumoral injection of radioactive colloid and methylene blue. Intraoperative identification of sentinel nodes was done using a handheld gamma probe and identification of blue-stained nodes. The nodes were sent for frozen section examination. The results of frozen section were compared with the final histopathology. Out of the 164 cases, metastases were detected in SLN by frozen section in 38 cases. There were three false-negative cases (all showing micrometastasis on final histopathology). FS had sensitivity of 92.6 %, specificity of 100 %, and overall accuracy of 98.1 %. The positive predictive value was 100 %, and the negative predictive value was 97.6 %. FS for diagnosis of metastasis of SLNs is reliable. Patients with negative SLNs by the FS diagnosis can avoid reoperation for axillary lymph node dissection. However, FS may fail to detect micrometastases, especially in cases with small tumors.

Keywords

Breast cancer Frozen section Sentinel node Axillary clearance 

References

  1. 1.
    Krag DN, Weaver DL, Alex JC, Fairbank JT (1993) Surgical resection and radio localization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol 2:335–340PubMedCrossRefGoogle Scholar
  2. 2.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL (1994) Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 220:391–401PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N et al (1996) Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA 276:1818–1822PubMedCrossRefGoogle Scholar
  4. 4.
    Veronesi U, Paganelli G, Viale G, Luiniurrida S, Galimberti V, Intra M et al (2006) Sentinel-lymphnode biopsy as a staging procedure in breast cancer: update of a randomised controlled study. Lancet Oncol 7(12):983–990PubMedCrossRefGoogle Scholar
  5. 5.
    Somashekhar SP, Zaveri Shabber S, Udupa Venkatesh K, Venkatachala K, Parameshwaran, Vasan Thirumalai MM (2008) Sentinel lymph node biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid—a single institution Indian experience. Indian J Surg 70:111–119PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Fitzgibbons PL, Page DL, Weaver D, Thor AD, Allred DC, Clark GM et al (2000) Prognostic factors in breast cancer. College of American Pathologists Consensus Statement. Arch Pathol Lab Med 120:966–978Google Scholar
  7. 7.
    Van Diest PJ, Torrenga H, Borgstein PJ, Pijpers R, Bleichrodt RP, Rahusen FD et al (1999) Reliability of intraoperative frozen section and imprint cytological investigation of sentinel lymph nodes in breast cancer. Histopathology 35:14–18PubMedCrossRefGoogle Scholar
  8. 8.
    Smidt ML, Besseling R, Wauters CA, Strobbe LJ (2002) Intraoperative scrape cytology of the sentinel lymph node in patients with breast cancer. Br J Surg 89:1290–1293PubMedCrossRefGoogle Scholar
  9. 9.
    Salem AA, Douglas-Jones AG, Sweetland HM, Mansel RE (2003) Intraoperative evaluation of axillary sentinel lymph nodes using touch imprint cytology and immunohistochemistry: I. Protocol of rapid immunostaining of touch imprints. Eur J Surg Oncol 29:25–28PubMedCrossRefGoogle Scholar
  10. 10.
    Nährig JM, Richter T, Kuhn W, Avril N, Flatau B, Kowolik J et al (2003) Intraoperative examination of sentinel lymph nodes by ultrarapid immunohistochemistry. Breast J 9:277–281PubMedCrossRefGoogle Scholar
  11. 11.
    Veronesi U, Zurrida S, Mazzarol G, Viale G (2001) Extensive frozen section examination of axillary sentinel nodes to determine selective axillary dissection. World J Surg 25:806–808PubMedCrossRefGoogle Scholar
  12. 12.
    Hill ADK, Tran KN, Akhurst T, Yeung T, Yeh SDJ, Rosen PP (1999) Lessons learned from 500 cases of lymphatic mapping for breast cancer. Ann Surg 229:528–535PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Zurrida S, Mazzarol G, Galimberti V, Renne G, Bassi F, Iafrate F, Viale G (2001) The problem of the accuracy of intraoperative examination of axillary sentinel nodes in breast cancer. Ann Surg Oncol 8:817–820PubMedCrossRefGoogle Scholar
  14. 14.
    Weiser MR, Montgomery LL, Susnik B, Tan LK, Borgen PI, Cody HS (2000) Is routine intraoperative frozen-section examination of sentinel lymph nodes in breast cancer worthwhile? Ann Surg Oncol 45:185–190Google Scholar
  15. 15.
    Chao C, Wong SL, Ackermann D, Simpson D, Carter MB, Brown CM et al (2001) Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer. Am J Surg 182:609–615PubMedCrossRefGoogle Scholar
  16. 16.
    Tanis PJ, Boom RP, Koops HS, Faneyte IF, Peterse JL, Nieweg OE et al (2001) Frozen section investigation of the sentinel node in malignant melanoma and breast cancer. Ann Surg Oncol 8:222–226PubMedCrossRefGoogle Scholar
  17. 17.
    Gulec SA, Su J, O’Leary JP, Stolier A (2001) Clinical utility of frozen section in sentinel node biopsy in breast cancer. Am Surg 67:529–532PubMedGoogle Scholar
  18. 18.
    Ratanawichitrasin A, Biscotti CV, Levy L, Crowe JP (1999) Touch imprint cytological analysis of sentinel lymph nodes for detecting axillary metastases in patients with breast cancer. Br J Surg 86:1346–1348PubMedCrossRefGoogle Scholar
  19. 19.
    Lee A, Krishnamurthy S, Sahin A, Symmans WF, Hunt K, Sneige N (2002) Intraoperative touch imprint of sentinel lymph nodes in breast carcinoma patients. Cancer 96:225–231PubMedCrossRefGoogle Scholar
  20. 20.
    Llatjós M, Castellà E, Fraile M, Rull M, Julián FJ, Fusté F et al (2002) Intraoperative assessment of sentinel lymph nodes in patients with breast carcinoma: accuracy of rapid imprint cytology compared with definitive histologic workup. Cancer 96:150–156PubMedCrossRefGoogle Scholar
  21. 21.
    Henry-Tillman RS, Korourian S, Rubio IT, Johnson AT, Mancino AT, Massol N et al (2002) Intraoperative touch preparation for sentinel lymph node biopsy: a 4-year experience. Ann Surg Oncol 9:333–339PubMedCrossRefGoogle Scholar
  22. 22.
    Kane JM III, Edge SB, Winston JS, Watroba N, Hurd TC (2001) Intraoperative pathologic evaluation of a breast cancer sentinel lymph node biopsy as a determinant for synchronous axillary lymph node dissection. Ann Surg Oncol 8:361–367PubMedCrossRefGoogle Scholar
  23. 23.
    Cserni G (2001) The potential value of intraoperative imprint cytology of axillary sentinel lymph nodes in breast cancer patients. Am Surg 67:86–91PubMedGoogle Scholar
  24. 24.
    Lambah PA, McIntyre MA, Chetty U, Dixon JM (2003) Imprint cytology of axillary lymph nodes as an intraoperative diagnostic tool. Eur J Surg Oncol 29:224–228PubMedCrossRefGoogle Scholar
  25. 25.
    Menes TS, Tartter PI, Mizrachi H, Smith SR, Estabrook A (2004) Touch preparation or frozen section for intraoperative detection of sentinel lymph node metastases from breast cancer. Ann Surg Oncol 20:1166–1170Google Scholar
  26. 26.
    Shiver SA, Creager AJ, Geisinger K, Terrier ND, Shen P, Levine EA (2002) Intraoperative analysis of sentinel lymph nodes by imprint cytology for cancer of the breast. Am J Surg 184:424–427PubMedCrossRefGoogle Scholar
  27. 27.
    Karamlou T, Johnson NM, Chan B, Franzini D, Mahin D (2003) Accuracy of intraoperative touch imprint cytologic analysis of sentinel lymph nodes in breast cancer. Am J Surg 185:425–428PubMedCrossRefGoogle Scholar
  28. 28.
    Mullenix PS, Carter PL, Martin MJ, Steele SR, Scott CL, Walts MJ, Beitler AL (2003) Predictive value of intraoperative touch preparation analysis of sentinel lymph nodes for axillary metastasis in breast cancer. Am J Surg 185:420–424PubMedCrossRefGoogle Scholar
  29. 29.
    Creager AJ, Geisinger KR, Shiver SA, Perrier ND, Shen P, Ann Shaw J et al (2003) Intraoperative evaluation of sentinel lymph nodes for metastatic breast carcinoma by imprint cytology. Mod Pathol 15:1140–1147CrossRefGoogle Scholar
  30. 30.
    Viale G, Bosari S, Mazzarol G, Galimberti V, Luini A, Veronesi P et al (1999) Intraoperative examination of axillary sentinel lymph nodes in breast carcinoma patients. Cancer 85:2433–2438PubMedCrossRefGoogle Scholar
  31. 31.
    Motomura K, Inaji H, Komoike Y, Kasugai T, Nagumo S, Noguchi S, Koyama H (2000) Intraoperative sentinel lymph node examination by imprint cytology and frozen sectioning during breast surgery. Br J Surg 87:597–601PubMedCrossRefGoogle Scholar
  32. 32.
    Noguchi M (2002) Sentinel lymph node biopsy and breast cancer. Br J Surg 89:21–34PubMedCrossRefGoogle Scholar
  33. 33.
    Krogerus LA, Leidenius MH, Toivonen TS, von Smitten KJ (2004) Towards reasonable workload in diagnosis of sentinel lymph nodes: comparison of two frozen section methods. Histopathology 44:29–34PubMedCrossRefGoogle Scholar
  34. 34.
    Boecker W, Borisch B, Connolly CE, Decker T, Dervan P, Drijkoningen M et al (2004) Discrepancies in current practice of pathological evaluation of sentinel lymph nodes in breast cancer. Results of a questionnaire based survey by the European Working Group for Breast Screening Pathology. J Clin Pathol 57:695–701PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Cserni G (2006) Histopathologic examination of the sentinel lymph nodes. Breast J 12:S152–S156PubMedCrossRefGoogle Scholar
  36. 36.
    Perry N, Broeders M, de Wolf C, TörnbergS H, von Karsa L (2006) European guidelines for quality assurance in breast cancer screening and diagnosis, 4th edn. European Communities, LuxembourgGoogle Scholar
  37. 37.
    Weiser MR, Montgomery LL, Susnik B, Tan LK, Borgen PI, Cody HS (2000) Is routine intraoperative frozen section analysis of sentinel lymph nodes in breast cancer worthwhile? Ann Surg Oncol 7:651–655PubMedCrossRefGoogle Scholar
  38. 38.
    Weaver DL, Ashikaga T, Krag DN, Skelly JM, Anderson SJ, Harlow SP et al (2011) Effect of occult metastases on survival in node-negative breast cancer. N Engl J Med 364(5):412–421PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Greene F (2010) Breast cancer. In: Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A (eds) AJCC cancer staging manual, 7th edn. Springer, New York, pp 417–460Google Scholar
  40. 40.
    Noguchi M (2002) Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes. Br J Surg 89:1505–1515PubMedCrossRefGoogle Scholar
  41. 41.
    Allred DC, Elledge RM (1999) Caution concerning micrometastatic breast carcinoma in sentinel lymph nodes. Cancer 86:905–907PubMedCrossRefGoogle Scholar
  42. 42.
    Dowlatshahi K, Fan M, Bloom KJ, Spitz DJ, Patel S, Snider HC Jr (1999) Occult metastases in the sentinel lymph nodes of patients with early stage breast carcinoma: a preliminary study. Cancer 86:990–996PubMedCrossRefGoogle Scholar
  43. 43.
    Viale G, Maiorano E, Mazzarol G, Zurrida S, Galimberti V, Luini A et al (2001) Histologic detection and clinical implications of micrometastases in axillary sentinel lymph nodes for patients with breast carcinoma. Cancer 92:1378–1384PubMedCrossRefGoogle Scholar
  44. 44.
    Giuliano AE, Kelemen PR (1998) Sophisticated techniques detect obscure lymph node metastases in carcinoma of the breast. Cancer 83:391–393PubMedCrossRefGoogle Scholar
  45. 45.
    Chen SL, Hoehne FM, Giuliano AE (2007) The prognostic significance of micrometastases in breast cancer: a SEER population-based analysis. Ann Surg Oncol 14:3378–3384PubMedCrossRefGoogle Scholar
  46. 46.
    Giuliano AE, Hawes D, Ballman KV, Whitworth PW, Blumencranz PW, Reintgen DS et al (2011) Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage invasive breast cance. JAMA 306(4):385–393PubMedCrossRefGoogle Scholar
  47. 47.
    Hansen NM, Grube B, Ye X, Turner RR, Brenner RJ, Sim MS, Giuliano AE (2009) Impact of micrometastases in the sentinel node of patients with invasive breast cancer. J Clin Oncol 27(28):4679–4684PubMedCrossRefGoogle Scholar
  48. 48.
    Langer I, Guller U, Viehl CT, Moch H, Wight E, Harder F et al (2009) Axillary lymph node dissection for sentinel lymph node micrometastases may be safely omitted in early-stage breast cancer patients: long-term outcomes of a prospective study. Ann Surg Oncol 16(12):3366–3374PubMedCrossRefGoogle Scholar

Copyright information

© Association of Surgeons of India 2013

Authors and Affiliations

  • S. P. Somashekhar
    • 1
  • Zahoor Ahmed Naikoo
    • 1
  • Shabber S. Zaveri
    • 1
  • Soumya Holla
    • 1
  • Suresh Chandra
    • 2
  • Suniti Mishra
    • 2
  • R. V. Parameswaran
    • 3
  1. 1.Dept. of Surgical Oncology, Manipal Comprehensive Cancer CentreManipal HospitalBangaloreIndia
  2. 2.Department of PathologyManipal HospitalBangaloreIndia
  3. 3.Department of Nuclear MedicineManipal HospitalBangaloreIndia

Personalised recommendations