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Intraoperative Sentinel Node Imprint Cytology

Intraoperative Sentinel Node Imprint Cytology. 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%

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Intraoperative Sentinel Node Imprint Cytology

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  1. Intraoperative Sentinel Node Imprint Cytology

  2. 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%)

  3. 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

  4. 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%

  5. 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

  6. 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 H&E • 4/7 found on IHC • Last case due to lobular carcinoma • Result time 25 minutes (median)

  7. 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

  8. 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

  9. Lee et al (Texas, 2002) • 65 cases • >90% stained with Diff-quik, rest with Pap. • Sensitivity of 65% • False negative rate 9% • One false negative H&E

  10. Shiver et al (2002) • Diff-Quik • Sensitivity 56% • False negative rate 12%

  11. 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 H&E

  12. Ratanawichitrasin (1999) • 60 cases with SN biopsy & axillary dissection • IIC alcohol fixed, stained with H&E • Sensitivity 98% • False negative rate 2.4% • 2 falsely negative SNs

  13. 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

  14. 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

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