United States and Canadian Academy of Pathology United States and Canadian Academy of Pathology

Breast Pathology Long Course Breast Pathology Long Course

11 March 2009 11 March 2009
Pathology Evaluation of Sentinel Nodes
Pathology Evaluation of Sentinel Nodes
:
:
Protocol recommendations and rationale
Protocol recommendations and rationale
Donald L. Weaver, MD
Donald L. Weaver, MD
Professor of Pathology Professor of Pathology
University of Vermont College of Medicine University of Vermont College of Medicine
Burlington, Vermont Burlington, Vermont
USA USA
Objectives
Objectives
To understand the prognostic continuumfor nodal
tumor burden
To understand how sentinel node evaluation enhances
identification of micrometastases
To understand survival impact of micrometastases
relative to macrometastases
To understand limitations of pathologic analysis of
sentinel nodes
To discuss evaluation and sampling strategies for
sentinel nodes
Basic recommendations
Basic recommendations
Thin gross sections (2 mm)
Embed and examine each slice
Examine one section from each block
If levels used, evenly space sections through the block
0.5 mm or 0.2 mm intervals may be rational
IHC not required
If used must explain it is for rapid screening, highlights
smallest metastases, still miss metastases under 0.1 mm
Number of positive axillary nodes
is a continuous variable
Nemoto: Cancer 1980;45:2917-24.
0
10
20
30
40
50
60
70
80
%
0 1 2 3 4 5 6-10 11-15 16-20 21+
number of positive axillary nodes
5-year overall and disease free survival
OS
DFS
Volumetric
Volumetric
Tumor
Tumor
Burden
Burden
Important AJCC/UICC 6
th
edition concepts
Codify quantitative nodal tumor burden
10 or more positive nodes (pN3)
4-9 positive nodes (pN2)
1-3 positive nodes (pN1)*
Micrometastases (pN1mi)
Metastases larger than 0.2mm but none larger than 2.0mm
Isolated tumor cells and cell clusters (pN0(i+))
No metastasis larger than 0.2mm
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*nodes with ITC only do not increase node count
Defining a micrometastasis
No single tumor deposit larger than 2.0 millimeters
Huvos: Ann Surg 1971; 173: 44-6.
Fisher: Cancer 1978; 42: 2032-8.
No difference in survival between
node negative and micrometastases
Tumor volume for varying numbers of spherical metastatic foci
Number Diameter (mm) Volume (mm
3
)
1 cell 0.02 0.0000042
1000 cells 0.02 0.004188
1 cluster (ITC) 0.2 0.004188
1,000,000 cells 0.02 4.188
8000 clusters 0.1 4.188
1000 clusters 0.2 4.188
125 clusters 0.4 4.188
1 micrometastasis** 2.0 4.188
**Volume estimates assume a spherical metastasis 2 x 2 mm. An ellipsoid micrometastasis
2 x1 mm will occupy one half the volume (2.1 mm
3
) of a spherical micrometastasis. ITC =
isolated tumor cell cluster.
1
1 or 2
2
3
The effect of tumor size and lymph node status
on breast carcinoma lethality. Michaelson et al.
15-yr survival
2.0-2.9 cm tumors
Mortality estimate:
1% per 1mm size
6% per each +LN
In none of the size
groups examined did
women with one
positive lymph node
have a statistically
significantly greater
death rate compared
with lymph node
negative women with
tumors of the same
size
The prognostic significance of micrometastases in breast cancer:
A SEER population-based analysis. Chen et al. Ann Surg Oncol
2007; 14:3378-3384. (1992-2003)
pN0 = 154,569
pN1mi = 11,405
pN1a = 43,746
% pN0 pN1mi pN1a
T1 75.9 61.0 49.4
T2 21.8 33.7 43.0
T3 1.8 4.2 5.6
T4 0.5 1.1 2.0
p = <0.001
pN0 = 154,569
pN1mi = 11,405
pN1a = 43,746
The prognostic significance of micrometastases in breast cancer:
A SEER population-based analysis. Chen et al. Ann Surg Oncol
2007; 14:3378-3384. (1992-2003)
% pN0 pN1mi pN1a
T1 75.9 61.0 49.4
T2 21.8 33.7 43.0
T3 1.8 4.2 5.6
T4 0.5 1.1 2.0
p = <0.001
Stage II Breast Cancer Rates
U.S. Women (50-64 yrs), 1992-2000
0
20
40
60
80
100
120
140
1
9
8
5
1
9
9
2
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Year
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1
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0
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0
Stage 2
Stage 2, N-
Stage 2, N+
Stage 2 unk
SLNB
UVM-NSABP sampling strategy
Protocol B-32 (experimental)
Sectioning
strategy
Thinly slice 2-3 mm
Formalin and embed
Evaluate initial section at
participating site
Used for treatment
Blinded analysis of occult
metastases at UVM
Correlate with outcome
H&E and CK IHC at 0.45
and 0.96 mm
Target accrual: 5600
Protocol closed: met accrual
Recommended SLN Protocol
Thinly slice gross lymph
node at intervals no
thicker than 2.0 mm
Examine one H&E
section from the surface
of the faced block
CK IHC for suspicious
findings
A
1
A
1
Correct
Facing
Wrong
X
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Patterns of missed and detected micrometastases
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pN0(i+)
pN1mi
pN0(i-)
pN0(i-)
Patterns of missed micrometastases for various strategies
Three levels
200 micron intervals
Two levels
1.0 mm interval
Four levels through block
500 micron (0.5 mm) intervals
Multiple levels through block
200 micron intervals
Alternative SLN Protocol #1
Thinly slice gross lymph
node at intervals no thicker
than 2.0 mm
Embed all slices
Face block
Set microtome at 5 microns
and mount levels: 1, 100,
200, and 300
Four levels through block
500 micron (0.5 mm) intervals
This protocol can be linked to NSABP B-32 outcome results for occult metastases
Alternative SLN Protocol #2
Thinly slice gross lymph
node at intervals no thicker
than 2.0 mm
Embed all slices
Face block
Set microtome at 5 microns
and mount levels: 1, 40, 80,
120, 160, 200, 240 etc
Multiple levels through block
200 micron intervals
This protocol has approximately 96% efficiency for detecting all ITCs present
Cytokeratin Immunohistochemistry
DOES NOT
guarantee the pathologist wont miss
isolated tumor cells and clusters
Occult SLN metastases identified by pathologist (LM) and computer
assisted cell detection with image analysis (CACD)
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91
largest occult metastasis (mm)
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CACD only
LM
Cancer 2006; 107:661-667
Pathologists will
miss isolated CK
positive tumor cell
clusters that are no
larger than 100
microns (0.1 mm)
B-32
236 cases screened
34/236 (14.4%) pos by LM
30/202 (14.9%) pos by CACD
IHC disproportionately identifies the
smallest category of metastases (ITC)
Systematic sectioning proportionately
identifies metastases
The practical solution
Agree on a:
statistically sound,
rational,
and economically efficient
protocol for screening sentinel nodes.
Accept we will miss metastases.
Reproducibly document what we find.