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For All Cancer Cases With Lymph Nodes (as of 11/11/02)

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 erroneous data]! 

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!

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.
 [intense node processing...how to do the nodes]

[the general agar process]

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).

References:

1. 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.
2.  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):

Outcome	neg. H&E neg. IHC (n=285)	neg. H&E pos. IHC (n=50)	pos. H&E pos. IHC (n=33)
15 yr DFS	81%	66%	50%
15 yr BCSM	16.1%	24.6%	45.3%

3. 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 update 3 April 2007]