|Thorough examination of lymph node specimens can be both technically rapid and cost effective. Regardless of the lack of any current consensus as to the
significance of isolated tumor cells and clusters < 0.2 mm in greatest
dimension (ITCs), excellence in surgical pathology practice requires
that a staging lymph node exam actually be truly negative when diagnosed as negative.
It, equally importantly, seems truly significant14 that pathologists discover every instance of malignant cells in a node, be they
individually dispersed lobular carcinoma cells or other malignant cells.
Whether they be true parenchymally invasive metastases or mechanically dislodged, in-transit, benign or malignant cells is an additional critical issue of morphological evaluation11,12. We offer a technique which assures permanently proveable, spaced stepcut sections and IHC-amplified detection of epithelial cells in lymph nodes removed for malignancy staging and with data pertaining to breast cancer.
The presence of metastatic carcinoma in axillary lymph nodes is the most
important prognostic indicator in breast cancer and provides crucial staging
information1. Various adjuvant therapies may be delivered more intensely in node positive than in node negative cases. Low grade small tumors may not get medical adjuvant therapy when node staging is diagnosed as negative. False negative node reports are not cost effective for the patient. The ADASP has published professional
recommendations for complete processing and reporting lymph node specimens submitted
for evaluation for metastatic disease2. The standard (with
exceptions) is that completion axillary node dissection is indicated when
sentinel node metastases are found3. Therefore it is essential to
detect a metastasis whenever present. A number of retrospective studies
performing amplified re-processing of archival cases originally designated negative
"by routine processing" have shown a conversion from node-negative to
node-positive cases on the order of 20-25%. 1, 4, 5, 6
We have developed a simple technique (http://www.palpath.com/MedicalTestPages/agards.htm#agarstick) for providing slide-based
documentary assurance to histotechnologists at time of stepsectioning and to the pathologist during case sign-out that lymph nodes processed according to ADASP
standards have been truly sampled at multiple levels as intended.
Following overnight fixation (we use 10% NBF as the standard for IHC & molecular but used to use Hartmann's fixative (http://www.palpath.com/MedicalTestPages/hartfix.htm)...alcoholic formalin & acetic acid), specimens are
thoroughly dissected in order to recover all lymph nodes 1-2 mm in diameter or
larger. Unless visibly positive, larger nodes are cross-sectioned at 2-3 mm
intervals and entirely processed and small nodes bissected or whole. A trilayered agar depth stick of different-colored layers (orange, yellow, and blue) is placed within an aggregate of small nodes or node cross
sections, which are then agar pre-embedded and placed into routine
processing cassettes. Further details of this process7 are posted
long-term on our website8. These blocks are then placed in with
the routine tissues for overnight tissue processing in our general pathology lab. The specimens are
embedded in routine fashion. When the histotechnologist mounts the block
into the microtome, the easily visible orange color of the "down" end (at
the block face) of the agar depth stick clues the histotechnologist to
section according to our "intense lymph node processing protocol" (http://www.palpath.com/MedicalTestPages/agards.htm). Slides
are cut for H&E staining from each third of the entire thickness of the
blocked node aggregate. A slide is taken from the middle or central third of
the block for immunostaining for pan-keratin antigen as a visibility-enhancing completion survey for occult malignant epithelial ITCs.
It is a prevailing belief that a step-cutting process for the multiple
lymph nodes of an axillary node dissection is a prohibitively expensive
process. Cost studies may paint a discouraging picture because they fail to
consider that any increase in cost is an incremental increase rather than a
new increase; therefore, the incremental cost is much less10. Because the embedded agar depth stick changes color each third of
the way through the block, our histotechs have found that this "intense
lymph node processing protocol" requires no more than 2-3 minutes per block.
That is, the presence of the agar depth stick marker allows the
histotechnologist to turn the microtome wheel very rapidly, proceeding from
first third, to the middle third, and to the deep third of the paraffin
block quickly and without hesitation.
Utilizing this process from 14 October 2002 through 13 October 2003, we
seven pathologists interpreted 135 breast cases with nodes and found 45 of
those cases (33%) to have one or more lymph nodes containing metastatic
tumor. Upon review of each of those cases, it is the author's opinion
(similar to the conversion rate of the study which inspired our technique9)
that as many as 12 (27%) of those 45 cases might have been missed by our previous routine
sections and about 4 of those 12 (9% of all positive cases) missed by a
microtome sectioning process which depended upon routine estimates of levels
by the histotechnologists rather than a controlled and documented process
that quickly and methodically forces one to sample at three or more spaced paraffin-block
through a 3 mm thickness of the lymph nodes.
Our group has used agar pre-embedding since 1978, and we are convinced
that the discipline that a multicolored marker embedded in the block gives
to the microtoming process easily allows a cost effective, more thorough, life-saving
exam of nodes at only a mildly increased investment in technologist and pathologist time. We offer the process in hopes that one or more major centers
will test it and confirm or refute its value. Most importantly, oncologists
(as ours do) can rest more assured that a "node negative" diagnosis by this method has a
significantly increased likelihood that the diagnosis is a "true-negative"
diagnosis. In the meantime within an evolving practice, we have added a fourth H&E slide at the point of disapparance of the colored agar stick, deep within the block. And, we are attracted to the idea of low powered microscopic exam of the fresh cut surfaces of the SLN13 prior to FS and with a rapid touch prep exam as a means of an initial morphological assessment with waiver of FS if negative touch prep.
- Yared MA, et. al., "Recommendations for sentinel lymph node processing
in breast cancer", Am J Surg Pathol 2002; 26(3):377-382.
- Association of Directors of Anatomic and Surgical Pathology. ADASP
recommendations for processing and reporting lymph node specimens
submitted for evaluation of metastatic disease. Am J Surg Pathol 2001;
- Van Zee KJ, et.al., "A Nomogram for Predicting the likelihood of
Additional Nodal Metastasis in Breast Cancer Patients with a Positive
Sentinel Node Biopsy", Ann Surg Oncol 2003; 10(10):1140-1151.
- Edwin R. Fisher MD,
S. Swamidoss MD,
C. H. Lee MD,
Howard Rockette PhD,
Carol Redmond SCD,
Bernard Fisher MD, "Detection and significance of occult axillary node
metastases in patients with invasive breast cancer." Cancer 1978;
- Hanna WM, et.al., "Pathologic Characteristics of Breast Cancer that
Predict for Local Recurrence After Lumpectomy Alone." Breast J 1999;
- Cote RJ, et.al., "Role of immunohistochemical detection of lymph-node
metastases in management of breast cancer. International Breast Cancer
Study Group." Lancet 1999; 354(9182): 896-900.
- Shaw EB, et. al, "Correct orientation of specimens for histologic
processing: Preliminary embedding in agar." Am J Dermatopathol 1983;
- Pathology Associates of Lexington, P.A. website
http://www.palpath.com/agards.htm, accessed 25 March 2004.
- Tan LK, Giri D, Panageas K, Cranor M, Bevilacqua J, Hummer A, Brogi E,
Norton L, Hudis C, Borgen P, Memorial Sloan-Kettering Cancer Center, New
York, NY, "Occult/micrometastases in axillary lymph nodes of breast cancer
patients are significant: a retrospective study with long-term follow-up",
presentation at the 2002 ASCO Annual Meeting,
accessed 26 April 2004.
- Weaver, DL, et.al., "Sentinel Lymph Nodes and Breast Carcinoma" AJSP
2003; 27(6): 842-845.
- Taylor CR & Cote RJ, Immunomicroscopy: A Diagnostic Tool for the Surgical Pathologist, 2nd Ed. 1994 (#19 in the series of Major Problems in Pathology), pages 233-235.
- Diaz NM, et. al., "Benign Mechanical Transport of Breast Epithelial Cells to Sentinel Lymph Nodes", AJSP 28(12) :1641-1645, December 2004.
- Varga Z, et. al., "Use of intraoperative stereomicroscopy for preventing loss of metastases during frozen sectioning of sentinel lymph nodes in breast cancer", Histopathology 52(5):597-604, April 2008.
- de Boer M, et. al. , "Micrometastases or Isolated Tumor Cells and the Outcome of Breast Cancer", NEJM 361(7):653-663, 13 August 2009.