Is Routine Intraoperative Frozen Section Analysis of Sentinel Lymph Nodes Necessary in Every Early-Stage Breast Cancer?

Abstract

Clinical application of the ACOSOG Z0011 trial results allows clinically node-negative breast cancer patients who meet criteria to avoid axillary dissection even when 1-2 sentinel lymph nodes (SLNs) are positive for metastatic disease. Intraoperative frozen section (iFS) analyses of SLNs were thought to reduce re-operation rates despite variable reported sensitivity and possibility of a false negative result. This study evaluated the rate of re-operations prevented by SLN iFS in a tertiary care hospital in Bangkok, Thailand, over a 6-year time-frame. Patients and Methods:From April 2016 to April 2022, 1284 sentinel lymph node biopsy (SLNB) procedures were performed. Of these, 214 cases were breast-conserving surgery in accordance with the ACOSOG criteria with concomitant usage of iFS. Clinicopathological features of these cases were collected and analyzed. Re-operation rates prevented by the additional intervention were reported. Results: Only five additional operations were prevented with the usage of 214 iFS. The discordance rate between frozen and permanent sections in terms of presence of metastatic disease and number of total lymph nodes was around 15%. Tumor staging, node staging, Nottingham histologic grading and lymphovascular invasion are significant predictors of SLN metastasis. Conclusion: iFS results in a very low prevention rate for follow-up ALND in patients with preoperative clinically negative axillary nodes and is associated with a non-negligible discordance rate with permanent sections. Our study suggests iFS may be avoided in most cases of early-stage clinically and radiographically node-negative breast cancer patients. Doing so may reduce surgical costs and total operative time without a significant impact on the overall quality of treatment and standard of care.

Reconsidering the Role of Intraoperative Frozen Section in Sentinel Lymph Node Biopsy for Mastectomy Patients with Early-Stage Breast Cancer: A 5-years retrospective review from King Chulalongkorn Memorial Hospital.

“…The primary objective of utilizing iFS is to minimize the need for a second operation. Studies have reported a false negative rate (of having less than 2 positive nodes) of 2-4% for iFS compared to PS [8, 9,14]. In our study, we observed a discordance rate of 4.9% between metastatic nodes detected on iFS and PS, but none of them exceeded a discrepancy of 2 positive nodes.…”

“…However, recent studies suggest that iFS may be unnecessary in early-stage breast cancer patients, where tumor size and axillary lymph node status can be used as prognostic factors [8,17]. This trend has already been observed in lumpectomy cases, where iFS has been found to confer minimal diagnostic value, in accordance with the ACOSOG criteria [13,14]. A recent randomized controlled trial conducted by The European Institute of Oncology of Milan (SOUND trial) even con rmed the safety of omitting SLNB in well-selected early-stage breast cancer patients who were treated with breast-conserving surgery and had no evidence of axillary node involvement by clinical and ultrasound evaluation [18].…”

Reducing the Use of Frozen Section for Sentinel Node Biopsy in Breast Carcinoma: Feasibility and Outcome

“…On the other hand, the reduction of the operative time may allow one or two more procedures to be scheduled every day in the surgical theatre, with considerable economical savings and boosted clearance of the waiting list. The reduction in health care costs associated with this change in management of SLNBs has also been highlighted by others (20,(36)(37)(38)(39)(40). However, others reported opposite conclusions, claiming an increase in costs with the use of PS-SLNB in consideration of a higher reoperation rate (41).…”

Assessment of PD-L 1 expression in a tumor improves the accuracy of predicting the risk of regional breast cancer metastases

“…Intraoperative pathologic assessment of SLNs requires skilled pathologists and equipment, which increases the surgical time and costs. Moreover, following the results of the Z0011 study, intraoperative frozen section analysis of SLNs in patients undergoing conservative breast surgery is considered inappropriate [16,17] . This is due to both the low sensitivity of the method (from 66.7% to 95.8%) and a wide range of false negative results (from 5.5% to 43%) [17,18] .…”

“…Moreover, following the results of the Z0011 study, intraoperative frozen section analysis of SLNs in patients undergoing conservative breast surgery is considered inappropriate [16,17] . This is due to both the low sensitivity of the method (from 66.7% to 95.8%) and a wide range of false negative results (from 5.5% to 43%) [17,18] . For the study of permanent sections, its main disadvantage is the need to perform a repeat operation in patients with ALN metastases.…”