| Lymph Node "Intense Processing Protocol"
[Back to Breast Cancer
For All Cancer Cases With Lymph Nodes (as
Grossing component of protocol = Lymph Node Dissection:
Warning: There is absolutely no call for rapid reporting
of a node dissection; this procedure yields results which send
the therapeutic chain of events down widely divergent pathways.
Recent separate look-back studies from Memorial Sloan-Kettering2 and
Queensland1 have found the reason that
25% of node-negative breast cancer cases have behaved
as node positive: the H&E and IHC step-cut reprocessing of
cases has documented a 25% node false negative rate in the original
node reporting of nodes processed "the old, classical way" [the
way on which all of our classical prognostic data is calculated...highly
Find all nodes taken out: So, our first step is to continue
our maximal effort at finding all nodes present in the delivered
specimen (be it SLN or other). By way of either a longer fixation,
or post-fixation in something like M2, firm the Hartmann's, 10%
NBF, or alcoholic-formalin fixed nodes enough (if need to) to be
able to cut cross sections between two and four millimeters in
thickness (never any thicker than four millimeters). As of the
end of 2002, we are doing this routinely only on breast and melanoma
cases, whether SLN or ALND.
Now, don't miss any positivity
within any node!
Histology Component of protocol:
Do not pack the cassettes overly full with specimens; always include
a tri-colored "agar depth stick" in each cassette (always
attempting to choose a stick that is approximately as thick
as the node sections in that block). The absence of an "agar
depth stick" will always tell Histology that only a single,
routine (one) H&E slide is to be produced per block (being
a block with a grossly positive node cross-section selected to
show hilar zone and any worst capsular penetration). Another way
to limit the work on a positive node is to do an informal frozen
section[LMC-05-761] on a probably-positive
node just to be sure (or submit it for a standard section...if
you are wrong, then order recut stepcuts through that node). Because
the colored agar retains its color in the slides, the pathologist
has the chance to observe that stepcuts actually came from all
three levels of specimen thickness, documenting entire sampling
through the 1-4 mm thickness of the cross-sections.
node processing...how to do the nodes]
[the general agar process]
Pathologist Diagnostic component = slide discernment:
An H&E and an IHC (pankeratin...maybe use ck20 for Merkle
cell) slide is taken at each of the three "agar depth
stick" color levels (six slides per block), and the one
slide that is routinely sent for IHC is within the middle color
zone of the agar depth stick…producing for sign-out:
3 H&Es and 1 IHC per block, and using only one IHC control
per case "run". Beginning in early 2007, we (1) added a 4th slide level "as the histotech sees the tissue thin to almost being
entirely cut away" & (2) the node grossing pathologist or PA is to make sure that an agar depth stick matching the thickness of the
thickest node piece in the casette is agar pre-embedded with the tissue.
An H&E and two IHC slides are taken at each of
the three "agar depth stick" color levels (nine slides
per block), and the two slides that are routinely sent for
IHC are within the middle color zone of the agar depth stick…producing
for sign-out: 3 H&Es and 2 IHCs per block and using only
one IHC control per each of the two case "runs".
IHCs are pan-melanoma and S-100 (to discern clusters of S100
positive melanoma cells which were HMB45 &/or pan-melanoma
negative...don't be fooled by the scattered dendritic macrophages
which are S100 positive).
- Cummings MC, "Occult
Ax. lymph Node Met. in Breast Cancer Do Matter...Results of
a 10-year Survival Analysis", The American J. of Surgical
Pathology 26(10):1286-1295, October 2002.
- 6/2002 ASCO (abstract 146,
Dr. Tan) report of retrospective analysis 368 ALNN mastect.
1976-78 @ Memorial S-K Hosp., ave. 17 nodes/patient, median
follow up 17.6 years (22.5% increased yield): 2 more step levels
(50 microns apart) H&E and IHC. Impact on DFS and breast
cancer specific mortality (BCSM):
|15 yr DFS
|15 yr BCSM
- Our first "intense protocol" case was LMC-02-7247.
LMC-02-7671 was first using agar depth sticks. LMC-02-6593
was first intense before protocol.
[Posted 11/11/02; latest slight update 19 January 2017]
1999 - 2006, all rights reserved, Pathology Associates Of Lexington,