Rapid intraoperative immunohistochemical evaluation of sentinel lymph nodes for metastatic breast carcinoma.

OBJECTIVE: Sentinel lymph node (SLN) biopsy is an integral part of the surgical management of patients with breast cancer. Rapid immunohistochemistry (RIHC) has the potential to increase detection of metastatic carcinoma at the time of frozen section consultation. The authors assessed the accuracy and turnaround time of a newly developed RIHC method for pancytokeratin (RIHC-CK). METHODS: Sixty-six SLNs from 32 patients with breast carcinoma were examined for metastasis using the Zymed Sentinel Lymph Node Rapid IHC Kit. Intraoperative frozen sections (6 mum) of the SLNs were incubated with Zymed anti-pan-cytokeratin/HRP conjugate, diaminobenzidine (DAB), and stained with hematoxylin. Slides were ready within 8 minutes and were interpreted as positive or negative for metastatic carcinoma. Results were compared with previous intraoperative touch preparations, frozen sections, hematoxylin and eosin (Perm H&E), and AEl/3-immunostained permanent sections (Perm CK). RESULTS: Fourteen lymph nodes (19%) in 13 patients tested positive for metastatic carcinoma in Perm H&E, the gold standard. RIHC-CK had the highest sensitivity (92%) of the intraoperative tests, compared with touch preparations (64%) and frozen sections (80%). RIHC-CK showed 94% accuracy, compared with 96% (frozen section) and 93% (touch preparation). The RIHC technique took 8 minutes and was easy to perform and interpret. CONCLUSIONS: Zymed RIHC is a sensitive method for detecting breast cancer metastases in SLNs. The speed, accuracy, and ease of interpretation of the test allow for recognition of micrometastases (<2 mm) that might otherwise be undetectable by current methods of intraoperative evaluation. The prognostic significance and effect on surgical management of micrometastases in SLNs have yet to be determined.

BRAF mutations in aberrant crypt foci and hyperplastic polyposis.

Patients with hyperplastic polyposis have multiple hyperplastic polyps (HPs) and increased risk of colorectal carcinomas. Aberrant crypt foci (ACF) are postulated to be the earliest precursor lesions in colorectal carcinogenesis. We evaluated BRAF mutations by DNA sequencing in 53 ACF from patients with sporadic colorectal carcinomas and familial adenomatous polyposis, in 18 sporadic HPs from patients with resected colorectal cancer, and in 70 HPs, 4 serrated adenomas, 3 admixed hyperplastic-adenomatous polyps, 10 tubular adenomas, and 6 carcinomas from 17 patients with multiple/large HPs and/or hyperplastic polyposis. BRAF mutation status was compared with clinicopathological features and other genetic alterations by marginal logistic regression. BRAF mutation was present in only 2% of ACF and 6% of sporadic HPs. In contrast, BRAF mutation was present in 43% of HPs (P = 0.01 versus sporadic HPs), 75% of serrated adenomas, 33% of admixed hyperplastic-adenomatous polyps, 30% of tubular adenomas, and 33% of carcinomas from patients with multiple/large HPs and/or hyperplastic polyposis. BRAF mutation status in patients with multiple/large HPs and/or hyperplastic polyposis correlated with HPs from the same patient (odds ratio, 5.8; P = 0.0002) but associated with younger age (odds ratio, 0.83; P = 0.006 compared to older age), with a large HP (odds ratio, 22.5; P = 0.01 compared with patients with multiple HPs), with location of HPs in the right colon (odds ratio, 3.0; P = 0.03), and with methylation of the p16 gene and the MINT31 locus [odds ratio, 12.2 (P = 0.0001) and 4.4 (P = 0.02), respectively]. Our study shows that BRAF mutation status is heterogeneous among patients with multiple/large HPs and/or hyperplastic polyposis, suggesting differences in pathogenesis of HPs that indicate subsets within this phenotype.

Rapid immunohistochemistry for cytokeratin in the intraoperative evaluation of sentinel lymph nodes for metastatic breast carcinoma.

The sensitivity and specificity of detecting metastatic breast carcinoma in sentinel lymph nodes using a rapid immunohistochemistry technique was determined and compared with methods currently used at the authors' institution. At the time of intraoperative consultation, after routine diagnostic touch preparations and frozen sections were prepared, 6-microm frozen sections of 72 sentinel lymph nodes from 32 patients with breast carcinoma were placed on plus slides, fixed in cold acetone for 2 or 3 minutes, and stored at -70 degrees C. These sections were immunostained with a prediluted broad-spectrum anticytokeratin monoclonal antibody coupled to an inert polymer with horseradish peroxidase (DAKO EPOS). Slides were ready for interpretation within 16 minutes and were scored as positive, negative, or equivocal for metastatic carcinoma. Results were compared with those of the intraoperative touch preparations and frozen sections and with paraffin-embedded, hematoxylin and eosin-stained, and AE1/AE3 immunostained permanent sections. Fourteen (19%) sentinel lymph nodes were positive for metastatic carcinoma in 13 patients. All methods tested were 100% specific. The rapid immunohistochemistry method was the least sensitive (57% sensitivity) of all methods used to detect metastasis. Routine diagnostic touch preparations, frozen sections, and permanent sections had sensitivities of 69%, 86%, and 100% respectively. In conclusion, this rapid immunohistochemistry method would not be helpful in intraoperative assessment of sentinel lymph nodes in breast cancer patients due to its low sensitivity.

Prostate cancer diagnosed after initial biopsy with atypical small acinar proliferation suspicious for malignancy is similar to cancer found on initial biopsy.

OBJECTIVES: To compare matched clinical and prostatectomy data between (a) men with an initial biopsy diagnosis of atypical small acinar proliferation (ASAP) suspicious for malignancy whose cancer was diagnosed subsequently, and (b) men with a cancer diagnosis not preceded by an ASAP diagnosis. ASAP diagnoses apply to 1.5%-9.0% of prostatic biopsies and predict definite cancer in about 45% of repeat biopsies. METHODS: At our hospitals, during overlapping intervals from 1990 to 2001, 7081 men underwent prostate biopsy, and 227 (3.2%) had an overall diagnosis (based on all cores sampled) of ASAP. We concurred with the ASAP diagnosis in 184 cases (81%). Repeat biopsy was performed in 129 (57%), with 22 again having ASAP and 51 (40%) adenocarcinoma. Nineteen men underwent prostatectomy at our hospitals. The controls comprised men who underwent prostatectomy before and after each man with an initial ASAP diagnosis (2:1 match with cases). Findings included grade, pathologic stage, measured maximum dimension of tumor, resection margin status, patient age, and latest preoperative serum prostate-specific antigen. RESULTS: Men in the initial-ASAP group did not differ significantly from controls with respect to age (63 vs. 61, P = 0.08). Initial-ASAP and control groups had serum prostate-specific antigen levels of 5.9 and 7.4 ng/mL (P = 0.32), respectively; mean Gleason scores were 6.2 and 6.6 (P = 0.11); mean stages were pT2b and pT2b; and tumor size averaged 0.9 and 1.2 cm (P = 0.36). Fewer men with initial-ASAP diagnosis on biopsy had positive margins (5%) than did those in the control group (30%, P < 0.05). CONCLUSIONS: An ASAP diagnosis represents undersampled cancer in at least 40% of cases and places men at risk of prostate cancer with similar clinicopathologic findings as in other men with cancer.