intraoperative cytology: past, present, and...
TRANSCRIPT
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INTRAOPERATIVE CYTOLOGY:
PAST, PRESENT, AND FUTURE
Steven G. Silverberg, M.D., FRCPath
Department of Pathology
University of Maryland, Baltimore
Presentation Bullet Points
• Intraoperative consultations are requested for a variety of reasons in addition to
diagnosis
• Cytology is increasingly utilized for microscopic assessment of intraoperative
specimens
• Advantages of intraoperative cytologic assessment include: accuracy, speed,
more complete sampling and preservation of specimen for later study.
• Intraoperative cytology is highly useful in evaluation of breast, parathyroid, CNS
and sentinel lymph node specimens.
Please see Dr. Silverberg’s PowerPoint presentation for his handout information.
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INTRAOPERATIVE CYTOLOGY:PAST, PRESENT, AND FUTURE
Steven G. Silverberg, M.D., FRCPathDepartment of Pathology
University of Maryland, Baltimore
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Presentation Bullet Points• Intraoperative consultations are requested for a variety of
reasons in addition to diagnosis• Cytology is increasingly utilized for microscopic
assessment of intraoperative specimens• Advantages of intraoperative cytologic assessment include:
accuracy, speed, more complete sampling and preservation of specimen for later study.
• Intraoperative cytology is highly useful in evaluation of breast, parathyroid, CNS and sentinel lymph node specimens.
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INTRAOPERATIVE CYTOLOGY:PAST, PRESENT, AND FUTURE
• Past: Breast• Present: Parathyroids• Future: Lymph nodes (inc.
sentinel)
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PARATHYROID EXPLORATION—TWO SERIES
Adipose tissue (1)
Lymph node/thymus (17)
Thyroid (19)
Parathyroid (111)
Tissue and Number
0
0
1 parathyroid
1 deferred
Cytologic Errors
0
1 parathyroid
1 parathyroid
2 deferred
Frozen Section Errors
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SENTINEL LYMPH NODES IN BREAST CANCER: INTRAOPERATIVE PATHOLOGIC EVALUATION
(Cserni, The Breast J 12:S152, 12/2006)
NOTE: False negative rates vary directly with extent of permanent section examination and proportion of micrometastases
False negative rate
Sensitivity
Accuracy
9-45%
55-91%
79-98%
Frozen Section
5-70%
46-96%
78-99%
“Imprint Cytology”
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BREAST CANCER SENTINEL LYMPH NODE EVALUATION: EUROPEAN
PATHOLOGY LABORATORY PRACTICE(Cserni et al, J Clin Pathol 57:695-701, 2004)
• 123 different protocols reported by 204 labs• IOC done in 61%, 69% of these are FS• European/German guidelines presented in
Cancer 103:451-461, 2005
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PUBLISHED GUIDELINES FOR INTRAOPERATIVE SENTINEL NODE ASSESSMENT
EWGBSP
Australia
Austria
Germany
UK
US/Consensus
US/CAP
Group
monograph only
www.cancer.org.au
www.pathology.at/sentinel.htm
Cancer 103:451, 2005
www.cancerscreening.nhs.uk
Hum Pathol 33:579, 2002
Arch Pathol Lab Med 12:1026, 2000
Reference
IOC = FS
IOC = FS
FS (2-3 from mid-portion)
Gross + IOC or FS
FS not recommended
IOC = FS
IOC > FS
Recommendation
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SENTINEL NODES IN BREAST CANCER:COMPARISON OF SMEAR TECHNIQUES
(Zhang et al, USCAP 2005)
• 462 smears → 65 positive, 383 negative, 14 inconclusive• 65 positive → 53 macromets, 7 micromets, 5? on permanent sections• 383 negative smears → 24 (6.3%) positive on H&E permanents
– 7 macro, 15 micro, 2 isolated tumor cells– 11 additional cases (2.9%) positive on CK-IHC only (all ITCs)
• 14 inconclusive → 5 (36%) positive on H&E permanents• False negative rate 14.5% in ILC, 4.4% in IDC (p=0.02)• Among 43 positive cases with 4 techniques available for review:
– 2 FN touch prep Diff-Quick,– 4 FN touch prep H&E,– 6 FN scrape smear DQ,– 4 FN scrape smear H&E
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PERSONAL RECOMMENDATIONS FOR INTRAOPERATIVE SENTINEL NODE ASSESSMENT
• No study if further immediate surgery not contemplated
• If needed, gross examination of multiple planes followed by smears of any gross lesion
• If no gross lesion, smears and imprints of each cut surface
• High false negative rate to be understood by the surgeon
• Ref: Treseler, The Breast J 12:S143, 12/2006
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VALUE OF INTRAOPERATIVE CYTOLOGY
RapidPreserves tissueLarge specimens
Multiple specimensNecrotic tissuesInfected tissues
Preparation for FNA
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Conclusions1. A wet-film method for the examination of new growths
and inflammatory tissues is introduced.2. The technique is very simple and requires no elaborate
apparatus.3. The time required for the preparation of the microscopical
speciman of a tissue removed at operation is from eight to ten minutes.
4. The method is unsuitable for post-mortem specimens. 5. Two hundred cases have been so examined and 191
correct diagnoses returned.6. Special experience of this method should be acquired
before it is employed in practice.