Abstract: Evaluation of Sentinel Lymph Node Intraoperative Frozen Section Diagnoses In Breast Cancer Patients

31 03 2009

Robstad, K. Department of Pathology. Albany Medical Center. Albany, NY

Objective: To evaluate the effectiveness of intraoperative frozen section diagnosis at appropriately staging patients undergoing breast cancer surgery at Albany Medical Center, and to compare these data to existing published reports.

Background: It has been established that selective axillary dissection guided by lymph node scintillography can reduce the morbidity associated with a full axillary lymph node dissection. The safety of this approach, however, is contingent upon accurate staging of the patient intraoperatively. False negative reporting may cause morbidity for the patient including additional surgery or disease recurrence.

Methods: A database search of pathology reports from 2003 to 2008 containing the keywords, “breast” and “sentinel node” was conducted using the SoftPath software suite. Diagnosis at the time of frozen section was compared to the final reported diagnosis. From this information, accuracies, sensitivities, and negative predictive values were calculated overall and by year for both cases as a whole and by total number of recovered sentinel lymph nodes. This data was then compared with figures reported in current literature.

Results: Between 2003 and 2008, there were 581 surgical cases in which intraoperative consultation was obtained regarding sentinel lymph node involvement by breast cancer; in these cases, a total of 1,647 lymph nodes were evaluated. The overall diagnostic accuracy at time of frozen was 96.28%. The overall sensitivity of detecting macrometastases was 80.34%. The negative predictive value was 95.62%. Data by year is reported in figures one through three.

Discussion: The data from the researched reports compares favorably with previously-published figures. Langer et al (2008) and Van de Vrande et al (2008) both report an accuracy of 90% compared with 96% at Albany Medical Center (AMC). Van de Vrande also documented a sensitivity of 84% in identifying macrometastases which compared to AMC’s 80% value. AlSahaf et al (2008) and Ali et al (2008) both report a negative predictive value of 97% which compares to AMC’s 95.6% value. Micrometastases were excluded from analysis because they have been found to have no impact on a patient’s prognosis; there were, however, 66 instances in which a case was reported as negative for tumor on frozen section that was  later designated to have involvement by either a focus of cancer measuring less than 0.2mm or isolated tumor cells (resulting in a N0i+ designation); only 23 cases were reported at AMC in which permanent sectioning revealed sentinel node involvement greater than 0.2mm which was not seen on frozen sections.

It is of note, that most published data compares frozen section diagnosis to the outcome of subsequent total lymph node dissection and not subsequent permanent fixation of the same specimen evaluated using frozen sectioning. Also, most existing publications fail to delineate the difference and micro- and macrometastases, making interpretation of existing data a complicated process. Finally, it is noteworthy that 12% of AMC case reports do not explicitly include a measurement of carcinoma involvement in the lymph node when not observed during intraoperative consultation.

 

 

CASES

2003

2004

2005

2006

2007

2008

Accuracy

95.24%

98.20%

98.91%

96.97%

94.31%

94.12%

Sensitivity

77.78%

90.00%

90.91%

82.61%

75.00%

73.08%

NPV

94.29%

97.85%

98.78%

96.46%

93.14%

93.00%

 

 

 

 

 

 

 

NODES

2003

2004

2005

2006

2007

2008

Accuracy

96.97%

99.28%

99.65%

98.41%

97.09%

97.31%

Sensitivity

70.00%

93.10%

92.86%

81.48%

75.76%

77.42%

NPV

96.74%

99.20%

99.64%

98.29%

96.80%

97.03%

 

Table 1. Accuracies, sensitivities and negative predictive values for overall cases and for individual nodes from 2003 to 2008.

 

References:

1.       Ali R, Hanly AM, Naughton P, Castineira CF, Landers R, Cahill RA, Watson RG. Intraoperative frozen section assessment of sentinel lymph nodes in the operative management of women with symptomatic breast cancer.  World J Surg Oncol. 2008 Jun 26;6:69.

2.       AlSahaf M, AlShaban B, Mulsow J, Power C, Leen E, Walsh TN. Intra-operative examination of the sentinel node in breast cancer.  Ir Med J. 2008 Apr;101(4):120-2.

3.      Davit FE, Gatmaitan P, Garguilo G. Sentinel node mapping for breast cancer: the operative experience of a breast surgeon in a rural community.

4.       Holwitt DM, Gillanders WE, Aft RL, Eberlein TJ, Margenthaler JA. Sentinel lymph node biopsy in patients with multicentric/multifocal breast cancer: low false-negative rate and lack of axillary recurrence.  Am J Surg. 2008 Oct;196(4):562-5. Epub 2008 Aug 29.

5.       Langer I, Guller U, Berclaz G, Koechli OR, Moch H, Schaer G, Fehr MK, Hess T, Oertli D, Bronz L, Schnarwyler B, Wight E, Uehlinger U, Infanger E, Burger D, Zuber M. Accuracy of frozen section of sentinel lymph nodes: a prospective analysis of 659 breast cancer patients of the Swiss multicenter study.  Breast Cancer Res Treat. 2009 Jan;113(1):129-36. Epub 2008 Feb 23.

6.       Van de Vrande S, Meijer J, Rijnders A, Klinkenbijl JH. The value of intraoperative frozen section examination of sentinel lymph nodes in breast cancer. Eur J Surg Oncol. 2008 Sep 9.

7.       Van Wely BJ, Smidt ML, de Kievit IM, Wauters CA, Strobbe LJ. False-negative sentinel lymph node biopsy. Br J Surg. 2008 Nov;95(11):1352-5.

8.     Varga Z, Rageth C, Saurenmann E, Honegger C, von Orelli S, Fehr M, Fink D, Seifert B, Moch H, Caduff R. Loss of metastatic deposits in breast sentinel lymph nodes during intra-operative frozen section analysis.  Verh Dtsch Ges Pathol. 2007;91:221-4.

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