PROTOCOL
SENTINEL NODE BIOPSY
(NON OPERATIVE)
BREAST CANCER -
PATHOLOGY
ASSESSMENT
Author: Dr Sally Ann Hales
On behalf of the Breast and pathology CNGs
Written: March 2005
Reviewed by CNG: June 2009 & June 2010
Revised: June 2011; and agreed at breast and pathology CNGs
Review Due: Dec 2012
Sentinel Node Biopsy – breast (June 2011)
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Preliminary notes
Not all patients will be suitable for sentinel node biopsy as an alternative to axillary clearance.
Patients with clinically-positive nodes will not be treated this way.
During the surgical training period, there is no justification for additional demands being
placed on pathologists to do more detailed dissections of the axilla looking, for example, for
blue nodes other than that identified by the surgeon. The surgical training period is to assess
whether the node identified as the sentinel node by the surgeon is predictive of the metastatic
status of the axilla.
The implications on pathology workload of the change in surgical practice are not precisely
defined, although it is likely that they will be broadly neutral. This may need auditing during
implementation.
There are no heath and safety implications for laboratory staff resulting from the use of
radioisotopes to localised the lymph nodes.
At present, it is not intended to perform intra-operative frozen section or touch imprint
reporting of sentinel node status. This is partly for logistical reasons, partly to reduce the
impact on laboratory staff and partly so as not to prolong the anaesthetic time during the
biopsy procedure. It is anticipated that only a relatively few patients will require a second
operation. This may need to be audited. However the main reason for not performing
intraoperative frozen section or touch imprint is the high false negative rate of these
techniques.
There are currently no national guidelines for the handling of sentinel nodes for breast
carcinoma. The following guideline is based on best practice after discussion with the breast
CNG pathologists and discussion at the NHS BSP QA big 18 Pathology section meeting 9th
Feb 2005 with input from Dr S Pinder, Dr L Lebrow and Dr G Cserni. It is recognised that the
scientific and prognostic value of the recognition of micrometastases and small numbers of
tumour cells is debatable. The view taken is that the objective histological information will be
recorded and that the surgeons and oncologists will decide how it should be conveyed to the
patient to inform therapeutic decisions.
This guideline is based on the pathology protocol from the Almanac trial ‘Randomized
Multicenter Trial of Sentinel Node Biopsy Versus Standard Axillary Treatment in Operable
Breast Cancer: The ALMANAC Trial’ Mansel et al 2006
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Laboratory Procedures
Specimen receipt
Sentinel nodes will be received as separate specimens in formalin [for cases where tissue
is currently received without fixative, the nodes will be unfixed].
Specimen handling
Describe colour (relate colour to any other lymph nodes within the axillary dissection
specimen during training phase).
Measure dimensions.
Tissue blocks
A representative complete section of any grossly involved node is adequate.
All other nodes should be serially sliced at intervals of 2mm or less perpendicular to long
axis and blocked in their entirety.
Sections
A single full face section should be examined for all SLNs
Take one H&E section from each block.
Stain by standard hematoxylin–eosin staining.
Lymph nodes smaller than 5 mm to be bisected and stained;
Lymph nodes 5 mm or larger to be sectioned at 3-mm intervals, and single sections
stained with hematoxylin–eosin
Slice the node at 2-3 mm intervals, embedding it in its entirety.
Examination of levels need not be part of routine practice.
Levels may be performed if small groups of worrisome cells are identified or for further size
measurement for sub classification into micro or macro metastases.
Immunohistochemistry
Take one H&E section with immunohistochemistry only if suspicious cells are seen
that need defining further
Molecular analysis
Research tool only.
Frozen Section + Imprint Cytology
Not to be used as a method for excluding involvement (research tool only). High risk
of false negative. False positives also reported.
Reporting
TMN
pN1 - metastasis >2mm
pN1 mic - larger than 0.2mm, no larger than 2mm, may have stromal reaction/proliferation
pN0 (i+) - no metastasis histologically, positive IHC, no cluster >0.2mm.
pN0 (i) - no metastasis histologically, no additional examination for isolated tumour cells.
Definition of isolated tumour cells – Single tumour cells or small clusters of cells no more than
0.2mm in greatest dimension. Usually detected by immunohistochemistry or molecular methods,
verified by H&E. Do not typically show proliferation/stromal reaction or penetration of vascular or
lymphatic sinus walls.
Sentinel Node Biopsy – breast (June 2011)
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Measurement
If multiple foci only largest is considered.
If single tumour cells or clusters or nests are continuous or separated by 2-5 cells
measure as one focus, with largest size.
If discontinuous and evenly dispersed measure as one.
If discontinuous and unevenly dispersed consider as one if distance between foci is
smaller than smallest cluster.
References:
1. NHS BSP QA Big 18 Pathology Section Meeting – 9 February 2005.
Input from Dr S Pinder/Der L Lebrow/Dr G Cserni.
2. Gerni, J Clin Pathol 2004; 57:467-471.
3. Cserni et al Ew J Cancer 2003; 30:1654-1667.
Association of Breast Surgery at Baso 2009. Surgical guidelines for the management of
breast cancer. Eur J Surg Oncol. 2009;35 Suppl 1:1-22
NHS Breast Screening Programme, Guidelines for Pathology Reporting in Breast Cancer
Screening, NHS Cancer Screening Programmes, 2005
Early and Locally Advanced Breast Cancer; Diagnosis and Treatement, NICE Clinical
Guidelines, No. 80, National Collaborating Centre for Cancer (UK); 2009.
Cserni G et al. Discrepancies in current practice of pathological evaluation of sentinel lymph
nodes in breast cancer. Results of a questionnaire based survey by the European Working
Group for Breast Screening Pathology. J Clin Pathol. 2004 Jul;57(7):695-701.
Fleming FJ et al. Factors affecting metastases to non-sentinel lymph nodes in breast cancer.
J Clin Pathol. 2004 Jan;57(1):73-6.
Cserni G et al. Meta-analysis of non-sentinel node metastases associated with
micrometastatic sentinel nodes in breast cancer. Br J Surg. 2004 Oct;91(10):1245-52.
Douglas-Jones AG, Woods V. Molecular assessment of sentinel lymph node in breast cancer
management. Histopath. 2009 Jul;55(1):107-13.
Takei H et al. Axillary lymph node dissection can be avoided in women with breast cancer
with intraoperative, false-negative sentinel lymph node biopsies. Breast Cancer. 2010;17(1):9-
16.
Pernas S et el. Avoiding axillary treatment in sentinel lymph node micrometastases of breast
cancer: a prospective analysis of axillary or distant recurrence. Ann Surg Oncol. 2010
Mar;17(3):772-7.
Giuliano AE, et al, Axillary dissection vs no axillary dissection in women with invasive breast
cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011 Feb
9;305(6):569-75.
Gutierrez J et al. Pathologic evaluation of axillary dissection specimens following unexpected
identification of tumor within sentinel lymph nodes. Arch Pathol Lab Med. 2011
Jan;135(1):131-4.
R I Cutress et al. Observational and cost analysis of the implementation of breast cancer
sentinel node intraoperative molecular diagnosis. J Clin Pathol 2010;63:522-529
Sentinel Node Biopsy – breast (June 2011)
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It is intended that this protocol will be revised one National Guidelines are available in the form of an
addendum to breast screening publication No 58
Sally Ann Hales, Consultant Pathologist
Accepted by the Pathology CNG and breast CNGs
Original Date March 2005 ; revised June 2011
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