Originally published as Ann Surg Oncol Early Release 10.1245/ASO.2004.01.014 on July 12, 2004
Annals of Surgical Oncology 11:747-750 (2004)
© 2004 Society of Surgical Oncology
Comparison of Frozen Section and Touch Imprint Cytology for Evaluation of Sentinel Lymph Node Metastasis in Breast Cancer
Tomohiko Aihara, MD, PhD,
Satoru Munakata, MD, PhD,
Hideo Morino, MD, PhD and
Yuichi Takatsuka, MD, PhD
From the Departments of Surgery (TA, YT) and Pathology (SM, HM), Kansai Rosai Hospital, Amagasaki, Hyogo, Japan.
Correspondence: Address correspondence and reprint requests to: Tomohiko Aihara, MD, PhD, Department of Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki, Hyogo 660-8511, Japan; Fax: 81-6-6419-1870; E-mail: aiharat{at}kanrou.net
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ABSTRACT
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Background: Sentinel lymph node metastasis of breast cancer is evaluated by frozen section (FS) or touch imprint cytology (TIC). However, which of the two methods is superior remains controversial. Here we directly compared the sensitivity of these methods prospectively.
Methods: The study included 208 SNs harvested from 107 consecutive patients with breast cancer who underwent sentinel lymph node biopsy. SNs were serially sectioned at 2-mm intervals, and two sections were subjected to intraoperative evaluation of FS with hematoxylin and eosin staining. TIC specimens were prepared from all cut surfaces and analyzed by Papanicolaou (TIC) and cytokeratin (TIC with immunohistochemistry; TIHC) immunohistochemistry.
Results: Thirty-five SNs from 27 patients were positive by final histopathology. The sensitivity per sentinel lymph node of FS was 89%; it was 86% for TIC and 89% for TIHC. Among 173 negative SNs, the results of FS were concordant with final histopathology, but TIC and TIHC were positive in 1 and 5 histopathology-negative SNs, respectively. The sensitivity per patient of FS was 85%; it was 85% for TIC and 89% for TIHC. Among 80 patients with node-negative disease, the results of FS and TIC were concordant with final histopathology, whereas TIHC was positive in 3 patients (3.8% were upstaged). A slight improvement of sensitivity per patient was achieved by the combination of FS and TIC (to 89%) or FS and TIHC (to 93%).
Conclusions: The sensitivity of FS was almost equivalent to that of TIC. TIHC had a better sensitivity than FS and TIC, but it upstaged a few node-negative patients.
Key Words: Sentinel lymph node • Frozen section • Breast cancer • Touch imprint cytology • Cytokeratin immunohistochemistry • Diagnosis
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INTRODUCTION
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Sentinel lymph node biopsy (SNB) accurately predicts axillary lymph node status in patients with primary breast cancer.1–3 Intraoperative evaluation of sentinel node metastasis facilitates immediate axillary dissection after SNB, which obviates the need for patients to undergo a second operation for axillary node dissection. Intraoperative frozen section (FS) or touch imprint cytology (TIC) is used for this purpose. FS analysis has been studied by many investigators and is commonly used in clinical practice, but the main disadvantage of this method is loss of tissue for definitive pathology. In addition, it is not practical to examine all the cut surfaces of all serial sections of harvested sentinel nodes because it is time consuming and expensive. Therefore, the number of cut surfaces that can be examined by FS is generally limited, which may limit its sensitivity. However, TIC does not lead to loss of tissue and allows examination of multiple cut surfaces at one time. Because of such advantages, TIC has been recommended for evaluation of sentinel nodes in patients with breast cancer.4–10 Although the sensitivity of TIC reported in those studies varies, several studies have reported excellent sensitivity.4–7
Two studies have directly compared the usefulness of FS and TIC for the diagnosis of sentinel node metastasis of breast cancer. Because the conclusion of one study contradicts that of the other, there is uncertainty about which is superior.6,8 The aims of this study were (1) to directly compare the sensitivity of FS and TIC as techniques for evaluation of sentinel node metastasis, (2) to determine whether the combination of methods improves the sensitivity, and (3) to determine the clinical significance of the immunohistochemical method of TIC (TIHC).
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PATIENTS AND METHODS
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This prospective study included 107 consecutive patients with breast cancer who underwent SNB with intraoperative FS analysis between August 2000 to March 2003. Patient characteristics are listed in Table 1. The median age was 53 years (range, 29–86 years). Forty-nine patients were premenopausal, and 58 patients were postmenopausal. Histopathologically, cases were classified as invasive ductal carcinoma (n = 90), microinvasive ductal carcinoma (n = 5), ductal carcinoma-in-situ (n = 5), mucinous carcinoma (n = 5), apocrine carcinoma (n = 1), and secretory carcinoma (n = 1). Eight patients received primary systemic therapy. Informed consent was obtained from each patient before the surgical procedure.
Intraoperative lymphatic mapping was performed with a peritumoral injection of 5 mL of .5% indigo carmine (Daiichi Pharmaceutical, Tokyo, Japan) with the patient under general anesthesia. A transverse skin incision was made in the axilla after 5 minutes of massage, and blue lymphatic channels were carefully pursued until they entered the lymph nodes. This was followed by wide resection of the primary tumor or mastectomy. Harvested sentinel nodes were serially sectioned at 2-mm intervals. In most cases, two sections were subjected to FS analysis. Three TIC specimens were prepared on silane-coated slides (Silane S; Muto Pure Chemicals, Tokyo, Japan) from all the cut surfaces. Those slides were fixed in 95% ethanol immediately. Two slides were subjected to Papanicolaou staining, and one slide was subjected to immunohistochemistry, which was performed with a Histofine Simple Stain kit (Nichirei, Tokyo, Japan). Briefly, slides were incubated with anti-cytokeratin antibody (AE1/AE3; Dako, Kyoto, Japan) for 45 minutes at room temperature after washing in Tris-buffered saline. The slides were again washed in Tris-buffered saline and then incubated with the secondary antibody conjugated with an amino acid polymer attached to peroxidase for 30 minutes at room temperature. 3,3'-Diamino-benzidine was used as the chromogen. The sections were counterstained with hematoxylin. Diagnoses were made by two investigators (S.M. and H.M.). The routinely used diagnostic categories were negative, suspicious, and malignant, but suspicious results were considered negative in this study. Sectioned sentinel lymph nodes were subsequently fixed in 10% neutral buffered formalin. Hematoxylin and eosin–stained sections were prepared by using a standard procedure.
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RESULTS
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Among 208 sentinel nodes from 107 patients, 35 from 27 patients were histopathologically positive sentinel nodes. The median number of sections obtained per sentinel node was 5 (range, 2–16). The sensitivity of FS, TIC, and TIHC per sentinel node was 89% (31 of 35), 86% (30 of 35), and 89% (31 of 35), respectively (Table 2). Table 3 shows a comparison of the results of FS and TIC and FS and TIHC on histopathologically positive sentinel nodes. The comparisons indicated a concordance rate of 91% (32 of 35) between FS and TIC and 89% (31 of 35) between FS and TIHC. Because of some discordant results, combining the results of FS and TIC or FS and TIHC improved the sensitivity to 91% (32 of 35) and 94% (33 of 35), respectively, from 89% with FS alone. Among 173 negative sentinel nodes, the results of FS were concordant with final histopathology, but TIC and TIHC were positive in 1 and 5 histopathologically negative sentinel nodes, respectively (Table 2).
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TABLE 2. Comparison of results of frozen section (FS), touch imprint cytology with Papanicolaou staining (TIC), and touch imprint cytology with immunohistochemical staining (TIHC) with those of histopathology on a sentinel node basis
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The sensitivity of FS, TIC, and TIHC per patient was 85% (23 of 27), 85% (23 of 27), and 89% (24 of 27), respectively (Table 4). Table 5 shows a comparison of the results of FS and TIC and FS and TIHC on patients with node-positive disease. The comparisons indicated a concordance rate of 93% (25 of 27) between FS and TIC and 89% (24 of 27) between FS and TIHC. Combining the results of FS and TIC or FS and TIHC improved the sensitivity to 89% (24 of 27) and 93% (25 of 27), respectively, from 85% with FS alone. Among 80 patients with node-negative disease, the results of FS and TIC were concordant with the final histopathology. TIHC was positive in three of those patients, and this resulted in upstaging of 3.8% of patients with node-negative disease (Table 4).
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TABLE 4. Comparison of the results of frozen section (FS), touch imprint cytology with Papanicolaou staining (TIC), and touch imprint cytology with immunohistochemical staining (TIHC) with those of histopathology on a patient basis
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DISCUSSION
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Several studies have addressed the usefulness of FS or TIC as techniques for evaluating sentinel node metastasis of breast cancer. However, only two studies have directly compared these two methods. Motomura et al.6 reported superior sensitivity of TIC over FS (96% vs. 52%). One pitfall of that study that may explain the inferior sensitivity of FS was the use of only one section of the largest sentinel node for FS when several sentinel nodes were harvested, whereas specimens for TIC were prepared from all cut surfaces from all harvested sentinel nodes. In contrast, van Diest et al.8 reported superior sensitivity of FS over TIC (87% vs. 62%). One pitfall of that study that may explain the inferior sensitivity of TIC is the staining method—that is, the sensitivity of TIC stained with the Quick Diff method was consistently inferior to that with Papanicolaou or hematoxylin and eosin, as we described previously.4–7 The differing conclusions between these articles can be explained by such pitfalls. One additional study compared FS and TIC, and it reported superior sensitivity of TIC over FS (94.2% vs. 85.7%).11 Because the study was conducted retrospectively and because the number of the sentinel nodes examined by FS (n = 479) and TIC (n = 165) was different, it was difficult to draw a definitive conclusion even when the results of this article were considered.
We demonstrated that the sensitivity of FS and TIC was almost equivalent under the conditions used in our study. Among the 27 patients with node-positive disease, FS and TIC yielded positive results in 24 patients, and 22 of them were consistently positive by both methods. Three patients with node-positive disease, with micrometastases <2 mm in diameter, were negative by both methods, which indicates that the detection of micrometastasis is similarly difficult in both methods. The sensitivity was improved from 85% with either method to 89% by combining the results of the two methods; however, it is practical and sufficient to use either method alone at the discretion of each hospital. TIHC correctly diagnosed disease in one of the three patients with micrometastasis who were overlooked by FS and TIC. Therefore, TIHC has the best sensitivity as a single diagnostic modality. TIHC can be applied to rapid intraoperative diagnosis by the use of immunofluorescence-labeled antibody.12 The difficulty of this method is the upstaging of histopathologically node-negative patients. In this cohort, 3 of 80 patients with node-negative disease were upstaged by TIHC, but not by FS and TIC. Because the clinical significance of micrometastases detected by immunohistochemistry is not established, the selection of the appropriate regimen of adjuvant therapy or the necessity for axillary lymph node dissection for such patients remains to be elucidated.
In conclusion, FS and TIC had almost equivalent sensitivity for evaluation of sentinel lymph node metastasis in breast cancer. Although combining the results of these two methods slightly improved the sensitivity and TIHC had a better sensitivity than FS and TIC, the use of either FS or TIC alone is sufficient as a clinical practice.
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ACKNOWLEDGMENTS
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The authors thank K. Oku, M. Yamane, K. Sugio, R. Yoshino, C. Kunito, and H. Kawakami for their excellent technical assistance.
The acknowledgments are available online in the fulltext version at www.annalssurgicaloncology.org. They are not available in the PDF version.
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FOOTNOTES
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The sensitivity of frozen section (FS), touch imprint cytology (TIC), and TIC with immunohistochemistry per patient was directly compared for evaluation of sentinel lymph node metastasis of breast cancer. The sensitivity of FS was almost equivalent to that of TIC.
Received for publication January 13, 2004.
Accepted for publication April 12, 2004.
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ABSTRACT
INTRODUCTION
