Axillary node staging by ultrasonography and fine-needle aspiration cytology in patients with breast cancer.

BACKGROUND: This study evaluated the role of axillary ultrasonography (AUS) and fine-needle aspiration cytology (FNAC) in preoperative staging of the axilla in patients with invasive breast cancer. METHODS: Between October 2006 and March 2009, 502 patients scheduled to undergo surgery for invasive breast cancer had preoperative AUS. All patients with suspicious nodes on ultrasonography underwent FNAC, and those with positive cytology proceeded directly to axillary node clearance. Patients with normal findings on AUS or negative cytology underwent sentinel node biopsy (SNB). RESULTS: A total of 137 (27.3 per cent) of 502 patients had axillary node metastases on final histology. Thirty-nine (28.5 per cent) node-positive patients were identified by AUS-FNAC and spared unnecessary SNB. AUS-FNAC had a sensitivity of 28.5 per cent and a specificity of 100 per cent for detecting axillary nodal metastases. AUS-FNAC findings were normal in all 15 patients with nodal micrometastases and in 11 patients with isolated tumour cells on histopathology. The sensitivity of AUS-FNAC had a positive correlation with invasive tumour size (odds ratio 1.03) and grade (odds ratio 2.80). CONCLUSION: Preoperative AUS-FNAC avoided unnecessary SNB in 28.5 per cent of node-positive patients and in 7.8 per cent of patients overall.

A pilot study of dual-isotope lymphoscintigraphy for breast sentinel node biopsy comparing intradermal and intraparenchymal injection.

AIMS: Identification of sentinel lymph nodes (SLN) may depend on the tissue plane of tracer injection. To explore this, we developed a dual-isotope technique to compare the lymphatic drainage basins accessed by intradermal and parenchymal injections. METHODS: Fifteen breast cancer patients had simultaneous parenchymal and intradermal injections of (99m)Tc-labelled human immunoglobulin G (HIG) and (111)In-HIG, respectively, 2-4h before axillary lymph node clearance surgery. All 228 freshly dissected nodes were assayed by well counting and examined for metastatic disease by haematoxylin/eosin staining and immuno-histochemistry. RESULTS: Total nodal uptake following intradermal injection was 10 times more than after parenchymal injection. Tracer uptake within the first three draining nodes divided patients into three groups; four (group 1) had identical 1st, 2nd and 3rd echelon nodes, six (group 2) had identical 1st and 2nd echelon nodes and five (group 3) had different 1st echelon nodes. With respect to the first, second and third groups, there was close, moderate and poor correlation (Pearson), respectively, between individual nodal counts accumulated from the two injection sites. Of eight patients with nodal disease, the SLN identified by intradermal and parenchymal injections contained disease in seven and four patients, respectively. CONCLUSIONS: Comparison of nodal tracer distributions from the two injection planes allows a functional model to be developed with two possible routes of drainage from the parenchymal plane, one joining the tract from the areolar plexus and the other passing independently to the axilla which builds upon Sappey's original anatomical model. This may explain the variable uptake, discordance and false negative SLN identification.

Expression of the WASP verprolin-homologues (WAVE members) in human breast cancer.

BACKGROUND: The WASP family proteins have been indicated to play a vital role in the formation of membrane protrusions required for cell locomotion. WAVE proteins are an important subfamily that also plays a crucial role in actin polymerisation, which is vital to cell migration. However, not much is known about the clinical significance of this subfamily in cancers. We report, for the first time, the expression of the WAVE molecules, at protein and mRNA levels, in human breast cancer. MATERIALS AND METHODS: The expression of the 3 WAVE molecules at the mRNA and protein levels in a cohort of 122 human breast cancers and 32 normal breast tissues were analysed and correlated with the patients' pathological and clinical information as well as outcome (120 months follow-up). RESULTS: All 3 WAVE molecules were detected in mammary tissues. WAVE2 transcripts were expressed in high levels in all breast tumours. Over-expression of WAVE2 was seen in node-positive cases as well as in moderately and poorly differentiated tumours. Also, high levels of WAVE2 expression were associated with death due to disease (p = 0.02) at follow-up. No distinct associations were found between the WAVE1 and WAVE3 transcripts and the breast cancer cells.

Immunohistochemistry increases the accuracy of diagnosis of benign papillary lesions in breast core needle biopsy specimens.

AIMS: Recent studies have suggested that benign papillary lesions without atypia [benign papilloma (BP)] diagnosed on breast core needle biopsy (CNB) may not require excision. However, most have studied only small numbers of cases and scant data are available on the utility of immunohistochemistry in the categorization of papillary lesions on CNB. In the largest published series of BP identified on CNB, we studied the impact of immunohistochemistry on the accuracy of a CNB diagnosis of BP. METHODS AND RESULTS: Breast CNBs (n = 129) with a diagnosis of papillary lesion were immunostained for calponin, p63 and cytokeratin 5/6. Haematoxylin and eosin and immunostained slides were independently reviewed by four breast pathologists. BP was the final excision diagnosis in 35 cases. With the use of immunohistochemistry, the positive predictive value (PPV) of BP diagnosis by the four individual pathologists increased from 72.7-83.3% (mean 79.2%) to 77.8-87.5% (82.1%), the negative predictive value (NPV) increased from 77.8-98.5% (88.6%) to 100% for all four participants and overall accuracy increased from 78.7-92.6% (84.7%) to 90.7-95.4% (92.8%). No case of invasive carcinoma was diagnosed as BP on CNB by any participant. The frequency of ductal carcinoma in situ following a BP diagnosis on CNB ranged from 2.5% to 4.8% (4%) but was only 0-3% (2.3%) after excluding cases that were radiologically suspicious for malignancy. CONCLUSIONS: Immunohistochemistry increases accuracy of BP diagnosis in CNB specimens. Benign papillary lesions diagnosed on CNB do not require excision in the absence of suspicious clinical/radiological findings.

Intraoperative evaluation of axillary sentinel lymph nodes using touch imprint cytology and immunohistochemistry. Part II. Results.

AIM: In order to operate selectively on positive axillae during the initial operative session for early breast cancer, an accurate and rapid intraoperative method to examine an axillary node sample (ANS) or a sentinel node biopsy (SNB) is required. The aim of this study was to determine the feasibility and accuracy of Immunohistochemistry (IHC)-stained touch imprints in detecting metastatic axillary nodes intraoperatively. MATERIAL AND METHODS: Four hundred and thirty-two axillary nodes from 52 patients (23 axillary node clearance (ANC), 15 ANS and 14 SNB) were bisected, imprinted and stained with anti-cytokeratin 19 IHC. Results were compared with those of routine haematoxylin and eosin (H&E)-stained sections. RESULTS: IHC imprints detected 32 positive nodes from 12 patients. H&E sections detected 31 positive nodes from 11 patients. IHC imprints missed metastases in three nodes and missed the diagnosis of positive axillae in two patients. H&E missed metastases in four nodes and missed the diagnosis of positive axillae in 3 patients. On a node-basis, sensitivities were 91.4 and 88.5%, negative predictive values (NPV) were 99.2 and 99.0% and overall accuracies were 99.3 and 99.1% for IHC imprints and H&E sections, respectively. On a patient-basis, sensitivities were 85.7 and 78.5%, NPVs were 95.2 and 93.1% and overall accuracies were 96.1 and 94.2% for IHC imprints and H&E sections respectively. There were no false positives. Interpretation of the results by a non-histopathologist was concordant with that of a histopathologist. Results might be obtained within 30-45 min depending on the number of examined nodes. CONCLUSION: Intraoperative IHC staining of touch imprints of axillary sentinel nodes is feasible and is a reliable method for evaluating axillary nodes. Slides can be reliably interpreted by a trained non-histopathologist.

Observer variability in the histopathological reporting of core biopsies of papillary breast lesions is reduced by the use of immunohistochemistry for CK5/6, calponin and p63.

AIM: To investigate agreement on core biopsy diagnosis of papillary breast lesions, which is acknowledged as a difficult area, and to determine the effect of the use of immunohistochemistry (IHC) to assist diagnosis. STUDY DESIGN: Haematoxylin and eosin (H&E) sections of 129 core biopsies of papillary breast lesions were circulated to four observers who categorized each case as: B2 (benign), B3a (epithelial proliferation, probably benign but requiring biopsy), B3b (epithelial proliferation with cytological or architectural atypia), B4 (probably malignant but insufficient material or artefact to allow diagnosis), B5 (malignant papillary lesion). In all cases (n = 127) IHC was performed for cytokeratin (CK) 5/6, calponin, p63 (myoepithelial markers), and slides recirculated. RESULTS: There was unanimous agreement in 44% of cases on H&E only which rose to 91% after the use of IHC. Overall, unweighted kappa (Ku; five categories) rose from 0.54 to 0.91. The main effect of IHC was to reduce the use of intermediate categories (B3a, B3b and B4) and allow definitive diagnosis (B2 or B5). CONCLUSION: Agreement on H&E sections alone in papillary core biopsies of breast is only 44% (Ku = 0.54) but is significantly increased to 91% (Ku = 0.91) by the use of IHC for CK5/6, calponin and p63.

Predictors of non-sentinel lymph node metastasis in breast cancer patients.

In many patients, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients would not be expected to benefit from completion axillary lymph node dissection (CALND). This study evaluated the factors that may determine the likelihood of additional positive nodes in the axilla in the presence of sentinel node metastasis. A total of 618 breast cancer patients underwent SLN biopsy based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99mTc-nanocolloid and Patent Blue V injected peritumourally. This was followed by standard axillary node clearance at the same operation. Of the 201 patients with a positive SLN, 105 (52%) patients had no further positive nodes in the axilla, 96 (48%) patients had additional metastasis in non-sentinel lymph nodes (NSLN) upon CALND. In patients with a positive SLN, increasing tumour size and tumour grade significantly increased the frequency of additional positive nodes on univariate analysis. The number of SLNs removed and the number of negative SLNs were significant negative predictors. Increasing tumour burden in the sentinel nodes (determined by the number of positive SLNs) was significantly associated with increasing likelihood of positive NSLNs. Multivariate analysis revealed that the rest of the axilla is more likely to be positive if there are more positive than negative SLNs removed and more likely to be negative otherwise. A group of cases from one centre (Cardiff) were subjected to further detailed analysis. Tumour burden in the positive SLN was assessed by measuring the size of metastasis, percentage replacement of the SLN by tumour and by documenting extracapsular extension (ECE) around the SLN. Of the 64 patients with a positive SLN, 34 (53%) patients had no further positive nodes in the axilla, 30 patients (47%) had additional metastasis in NSLNs upon CALND. Increasing tumour burden in the SLN was associated with additional positive nodes in the axilla. Multivariate analysis revealed that size of the SLN metastasis is the most important predictor of involvement of only the SLN. Overall, in patients with a positive SLN, the difference in the number of positive and negative SLNs removed and size of the metastasis in the SLN, all predicted the frequency of additional positive nodes.

Radial intratumoral increase and correlation of microvessels and proliferation in solid breast carcinoma.

AIMS: To compare correlations between different morphometrically assessed measurements of tumour microvasculature and to identify those which show closest correlation with Ki67 and to examine radial intratumoral distribution of microvessels and proliferation. METHODS AND RESULTS: Immunohistochemically defined microvessels and Ki67+ cells were quantified in sequential fields of 0.12 mm2 (x600) in four transects in each of five tumours. The total number of vessels (TNV) correlated more closely with proliferative activity than the numbers of vessels with a discernible lumen (TLV) and TNV decreased towards the centre of the tumour whereas TLV did not. A higher proliferative index (PI) was found at the periphery of the tumours. Comparison between transects through subjectively identified microvessel hot-spots and non-hot-spot transects showed similar mean, median and peak vessel counts but showed a different distribution on chi2 analysis. CONCLUSIONS: TNV correlates most closely with PI in breast carcinomas. There is marked variation in microvessel density and PI between fields of 0.12 mm2 but there is a significant radial reduction in both from the edge towards the centre of tumours.

Intraoperative evaluation of axillary sentinel lymph nodes using touch imprint cytology and immunohistochemistry: I. Protocol of rapid immunostaining of touch imprints.

AIMS: Sentinel Node Biopsy (SNB) is considered an accurate method of detecting axillary lymph node status in patients with small breast cancer. Combined with an accurate and rapid histopathology tool, it could spare this group of patients unnecessary Axillary Node Clearance (ANC) with its associated hazards. Intraoperative examination of SNB for cancer cells has been investigated using both Frozen Sections (FS) and Imprint Cytology (IC) stained with different stains. This study is devoted to establish a reliable and rapid protocol for immunostaining of touch imprints from SNB. METHODS: We investigated two different EPOS (Enhanced Polymer One-Step staining--DAKO) anticytokeratin antibodies, five different tissue fixatives and different incubation periods and temperatures with both positive and negative controls. RESULTS: We have developed a protocol, which produced good and consistent immunostaining of touch imprints. The initial results using this protocol are concordant with those of permanent Haematoxylin and Eosin (H&E) sections. CONCLUSIONS: We propose this protocol for rapid immunostaining of touch imprints of SNB.

Evaluation of axillary lymph nodes using touch imprint cytology and immunohistochemistry.

BACKGROUND: The success of sentinel node biopsy in determining axillary lymph node status necessitates an accurate and rapid method for intraoperative examination of the nodes. The aim was to determine the feasibility and accuracy of immunohistochemistry (IHC) of touch imprints in detecting axillary nodal metastases intraoperatively. METHODS: Some 344 axillary nodes from 30 patients with early breast cancer were bisected, imprinted and subjected to IHC. Results were compared with those of routine haematoxylin and eosin examination of the same nodes. RESULTS: Using IHC, 29 nodes from nine patients were positive for metastases. Using haematoxylin and eosin, 28 nodes from eight patients were positive. On a patient basis, the sensitivities of IHC and haematoxylin and eosin were 100 and 88.9 per cent, and negative predictive values (NPVs) were 100 and 95.5 per cent, respectively. On a node basis, the sensitivities were 96.7 and 93.3 per cent, and NPVs were 99.7 and 99.3 per cent, respectively. There were no false positives. The results were obtained within 30-45 min, depending on the number of nodes examined. CONCLUSION: IHC of touch imprints can provide a fast and sensitive method for detecting metastases in axillary nodes during breast cancer surgery.

Diagnostic difficulty arising from displaced epithelium after core biopsy in intracystic papillary lesions of the breast.

This study reports two cases of intracystic papillary carcinoma of the breast, which had been biopsied preoperatively using a 14 gauge (14G) core biopsy needle. In each case, a needle tract containing groups of epithelial cells within granulation tissue could be identified on histology of the excised specimen. Both cases showed extracapsular tumour, which was interpreted as displacement of epithelium related to preoperative core biopsy. Subsequent axillary lymph node sampling showed no evidence of metastasis. In one case, extracapsular tumour appeared to be in blood vessels, but flattened cells lining the spaces containing tumour failed to react with factor 8 related antigen or CD34 on immunohistochemistry. It is likely that intracystic papillary carcinomas are particularly prone to this artefact because friable tumour fragments escape, accompanied by cyst fluid, when the capsule is punctured by a 14G core biopsy needle.

Effect of margins of excision on recurrence after local excision of ductal carcinoma in situ of the breast.

AIMS: To determine important factors influencing recurrence after local excision of duct carcinoma in situ (DCIS) of the breast. MATERIALS AND METHODS: The extent (size) in millimetres, classification (by cytonuclear grade (NHSBSP system), by extent of necrosis, and by the Van Nuys system), and excision margins of 115 cases of screen detected DCIS treated by local excision were measured. A prognostic index was calculated by the addition of the Van Nuys classification (low grade, 1; moderate grade, 2; high grade, 3), margin score (> or = 10 mm, 1; 1-9 mm, 2; < 1 mm, 3), and size score (< or = 15 mm, 1; 16-40 mm, 2; and > or = 41 mm, 3), giving a total score of 3-9. RESULTS: Classification using cytonuclear grade, extent of necrosis, or the Van Nuys system did not correlate significantly with recurrence. The excision margin (in millimetres) was associated with recurrence (p = 0.027) and if excision margin status was simplified using the scoring system (> or = 10 mm, 1; 1-9 mm, 2; < 1 mm, 3), the margin score was significantly associated with recurrence (p = 0.03). A prognostic index based on the Van Nuys score, margin status, and size was significantly associated with recurrence (p = 0.003). CONCLUSION: The results support the hypothesis that the margin of excision is the most important factor predicting the recurrence of DCIS after local excision.

The effect of fixation and processing on the sensitivity of oestrogen receptor assay by immunohistochemistry in breast carcinoma.

AIMS: To investigate the effect of different fixation and processing regimens on the assessment of oestrogen receptor (ER) by immunohistochemistry (IHC). METHODS: The ER results for 420 patients from seven different hospitals in which antigen retrieval and IHC were performed centrally were compared. The intensity of ER positivity was assessed semiquantitatively using the Quick score (range 0-7). The scoring profiles of cases from each different source (hospital) were compared to detect differences in the proportion of cases that were negative (Quick score = 0), moderately positive (Quick score = 1-5), and strongly positive (Quick score = 6-7). RESULTS: There were no significant differences (p = 0.3; kappa(2) test) in the proportion of cases in each category. CONCLUSIONS: None of the fixation or processing regimens had a significant adverse effect on the sensitivity of the ER assessment performed by automated immunohistochemistry.

Comparison of core oestrogen receptor (ER) assay with excised tumour: intratumoral distribution of ER in breast carcinoma.

AIMS: The use of the H score (involving the assessment of intensity and distribution of positivity) on sections stained for the oestrogen receptor (ER) by immunocytochemistry (ICC) allows different samples to be compared and detailed correlations to be made between hormone receptor expression and morphology. This study assessed the reliability of core biopsy in predicting ER expression in the same tumour excised later at treatment. The distribution of ER within excised tumours was investigated. METHODS: The distribution of ER positivity was investigated in 51 diagnostic core biopsies and across the diameter of 51 subsequently excised tumours in a field by field (magnification, x40; field diameter, 0.4 mm) assessment using the semiquantitive H scoring system. RESULTS: The ER H score in diagnostic core biopsy was significantly higher (p = 0.05, paired rank test; overall mean, 130; n = 51) than the mean in the corresponding excised tumour (mean, 110; n = 51). There was a significant downward trend in ER positivity from the periphery of tumours towards the centre (p = 0.001). The reduction of ER positivity was 6 H score units (2%)/mm. If core biopsies were orientated with the tumour edge at one end no change in ER positivity with field number along the length of the core could be demonstrated. CONCLUSIONS: ER estimation in core biopsies correlated well with expression in tumours but ER expression was higher in the core biopsies than in the excised tumours. ER expression was higher at the periphery of tumours than at the centre. The higher ER expression in cores may reflect the higher chance of sampling the peripheral part of a tumour using a needle core.

Conversion to core biopsy in preoperative diagnosis of breast lesions: is it justified by results?

AIMS: In recent years there has been increased use of core biopsy for the preoperative diagnosis of screen detected and symptomatic breast lesions. The aim of this study was to compare the quality assessment parameters for preoperative diagnosis by fine needle aspiration cytology (FNAC) before conversion to core biopsy with those for core biopsy after conversion in screening and symptomatic practice. Accuracy of typing and grading of tumours on core biopsy was assessed. METHODS: Correlation of FNAC (C1-5) and core biopsy (B1-5) results (total of 1768 cases) with subsequent available resection histology was performed for 473 FNAC samples in 1997/98, 349 core biopsies in 1998/99 performed in symptomatic practice, for 561 FNAC samples in 1997/98, and 385 core biopsies in 1998/99 performed in screening. Quality assessment parameters were calculated using the methodology detailed in the National Health Service Breast Screening Programme guidelines for cytology practice. RESULTS: Increased absolute and complete specificity, lower inadequate rates, and lower suspicious rates were found for core biopsy compared with FNAC in both symptomatic and screening practice. Typing of tumours was attempted in 86.7% of core biopsies in symptomatic practice and was accurate in 93.6% (132 of 141 where type was stated). Grading of tumours was attempted in 63.5% of invasive carcinomas, with the provisional grade on core biopsy being confirmed on later histology in 75% of grade 1 cases, in 70% of grade 2 cases, and in 86% of grade 3 cases. No case provisionally graded as 1 was subsequently found to be grade 3 and no provisionally grade 3 case was found to be grade 1. CONCLUSION: Conversion to core biopsy for the preoperative diagnosis of breast lesions increases specificity and reduces inadequate and suspicious rates. Grading and typing of tumours and assessment of oestrogen receptor status by immunocytochemistry is also possible in core biopsy, thereby increasing diagnostic information available when considering treatment options.

Combined wide excision and mastopexy/reduction mammoplasty for inframammary hidradenitis: a novel and effective approach.

Hidradenitis suppurativa is a rare chronic skin condition involving the apocrine glandular zones, which are found predominantly in the axilla and inguinoperineal regions, but have been described at other sites, including the inframammary fold. Treatment requires complex surgical intervention with wide excision of involved tissue. Inframammary hidradenitis tends to affect young women and can prove resistant even to this radical form of surgery, which often results in marked scarring and breast deformity. We therefore decided to adopt a novel approach by incorporating the wide excision of inframammary skin currently necessary in a reduction mastopexy procedure. This enables primary closure with ptosis correction and should improve cosmesis. The reduction in the depth of the inframammary fold also makes hygiene easier in the long term. During a 6-year period, five patients (mean age 27 years) have been treated by this method. All patients had long-standing hidradenitis (mean 12 years), and had been treated with several courses of antibiotics. A modified Wise pattern reduction incision was used with a minimum amount of breast tissue being removed. In each case histology was consistent with hidradenitis. All wounds healed well and to date there have been no inframammary recurrences. The success of this operation in curing inframammary hidradenitis has had a dramatic affect on the lives of these young women and underlines the need for this rare condition to be treated in a specialist centre.

Rapidly enlarging lump in the neck: is it a tumour?

A rapidly enlarging lump in the neck of an adolescent, is a cause for concern. Amongst the various clinical differential diagnoses, including lymphoma and other malignant lesions, focal myositis is an unusual cause. To date, only two such cases affecting the sternomastoid have been reported worldwide. We report a further similar case.

Consistency in the observation of features used to classify duct carcinoma in situ (DCIS) of the breast.

AIM: To determine interobserver and intra-observer agreement in the assessment of cytological grade and intraduct necrosis in pure duct carcinoma in situ (DCIS) of the breast. METHODS: Sixty unselected cases with illustrated diagnostic criteria were circulated to 19 practising histopathologists. RESULTS: Overall agreement was moderate for cytological grade in three categories: 71% agreement; weighted kappa (kappa w), 0.36; intraduct necrosis in three categories (absent, present, extensive): 76% agreement; kappa w, 0.57; and the Van Nuys classification system: 73% agreement; kappa w, 0.48. Agreement was no better among observers participating in the National External Quality Assurance Programme. Intra-observer agreement for cytological assessment (69.6% agreement; kappa w, 0.52) and intraduct necrosis (68.3% agreement; kappa w, 0.48) was moderate, suggesting that individual variation rather than precision of criteria contributes to the lack of agreement. CONCLUSIONS: Moderate agreement on observations can be achieved by non-specialist pathologists, with better agreement on necrosis than cytological grade. There was evidence of consistent individual bias towards over or under scoring cytological grade, which could be corrected with adequate and prompt feedback.