Axillary sentinel lymph node cytopathology in Norwich - ESQA

Pathological assessment of thesentinel lymph nodeImmediate – intra-operative• Frozen section histopathology• CytopathologyDelayed• Conventional histopathology

Imprint cytology of axillary SLN- Positive

Imprint cytology of axillary SLN- Positive

Imprint cytology of axillary SLN- Artefacts

1. Research studySLN identified by subdermal injection of• Patent blue V dye– 119 patients (85.6%)• Patent blue V dye + radioisotope– 20 patients (14.4%)

1. Research study• Mastectomy: 51 (38%)• Breast-conserving surgery: 82 (62%)• Axillary nodes removed:– Mean 11.3 (range 5 – 27; median 11)– Metastatic disease 53 patients (40%)• SLNs identified– Mean 1.11 (range 1 – 3)

1. Research study• Slides stained with– Rapid Romanowski method (DiffQuik)– Standard May-Grünwald-Giemsa– MNF 116 anti-cytokeratins antibody• Classified as– Definitely positive for metastatic cancer– Definitely negative for metastatic cancer– Indeterminate

1. Research study• Air-dried slides reported at– UCL (Dr Kocjan)– NNUH (RYB)• Comparison between centreswith histopathological findings• Intra-operative assessment (RYB)– Final 26 patients– Feasibility of technique as tool in management• Did not alter management in these patients

1. Research studySLN histology versus Paraffin-wax sectionscytology reporting Positive NegativeImprintcytologyPositive 36 3*Negative 6 86*Confirmed by immunocytochemical staining.Suggests micrometastasis lost during trimming in ofparaffin-wax block

1. Research studyTumour +veaxillaTumour -veaxillaImprint Positive 37 2cytology ofSLN Negative 16* 76•10/131 (7.6%) “skip” lesions – likely to be less now (

1. Research studyIntra-operative SLN assessment• 26 patients– Node-positive: 7– Node-negative: 19• 24 (92.3%) intra-operative diagnoses correct– False negative cytology = 1 (3.8%)– Indeterminate cytology = 1 (3.8%)– False positive cytology = 0

1. Research studyIntra-operative SLN assessment• Mean time to report = 24.5 min– Slides leaving theatre → report received

1. Research studyIf these observations had driven decision onaxillary dissection:• 6 (23.1%) immediate axillary dissections• 19 (73.1%) spared extensive axillary surgery– Indeterminate regarded as negative• 1 patient (3.8%) → second operation todissect axilla

1. Research studySens itySpec ityPPVNPV%%%%CytologyRoutine(131 cases)Operative(25 cases)Node Axilla Node Axilla Node Axilla Node Axilla86 70 97 97 92 95 93 8386 86 100 100 100 100 95 95Indeterminate cases excluded from analysis

2. Recent intra-operative use• Intra-operative SLN cytology now part ofclinical practice– What we say matters!• Audit carried out by Seema Angra (SHO)– Value of cytokeratin ICC– Effectiveness of service– Diagnostic difficulties

2. Recent intra-operative use• 6 cytopathologists now involved– Steep learning curve– Double-reading when difficult• Slides stained with– Rapid Romanowski method (DiffQuik)– MNF 116 anti-cytokeratins antibody

2. Recent intra-operative useDiffQuikCK ICCSensitivity 41.3% 58.7%Specificity 100% 100%PPV 100% 100%NPV 84.9% 88.9%

2. Recent intra-operative use• ↓ sensitivity•Why?– Erring on the side of caution• Avoid false positive reports– Technical difficulties• Slide preparation• Slide interpretation

2. Recent intra-operative useOver to Anne Girlingfor discussion ofhistopathological aspects

2. Recent intra-operative useCytopathology reportPositive DiffQuik staining 19 / 198 (9.6%)Positive CK ICC staining 27 / 191 (14.1%)Histopathology reportPositive SLN 46 /198 (23.2%)Positive cases reportedas negative at operation27 / 198 (13.6%)

2. Recent intra-operative use• We have abandoned routine CK ICC inthese cases– No value in the intra-operative context• Should we undertake– Intra-operative ultrarapid CK ICC method?– Frozen sections?