Sentinel and regional lymph nodes -breast

Background

Lymph nodes are common components of radical resections for malignancies. Sentinel lymph node excision 1 and lymph node dissections are undertaken to assess extent of regional node tumour metastases.

This protocol includes sentinel node and regional lymph node dissections involved in breast cancer axillary clearance. Separate protocols are provided for neck dissections and melanoma lymphadenectomies.


Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe.
  • Yes
    • Special studies required, describe.
    • Ensure samples are taken prior to fixation. 2
Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Sentinel node biopsy
    • Frozen section
    • Imprints
    • Other, describe

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Options
  • Sentinel lymph node
  • Axillary clearance/regional lymphadenectomy/lymph node dissection
  • Other, describe

Specimen site 2

Options
  • Axilla
  • Other, describe

Specimen description

Sentinel lymph node excision
  • Specimen size in three dimensions (mm) 1
  • Radioactive count if known 4
  • Uptake of dye 4
    • No
    • Yes
  • Number of lymph nodes
  • Size of each lymph node in three dimensions (mm) 4

Protocols for the safe handling of radioactive tissue should be established in laboratories receiving sentinel lymph node biopsies. Consideration of the number of samples to which staff are exposed, the length of time specimens are left for radioactivity to degrade before macroscopic cut-up commences and the correct disposal of waste material. 5,6

Regional lymph node dissection
  • Specimen size in three dimensions (mm) 1
  • Number of lymph nodes 4
  • Range of maximum diameters (mm)
  • Largest macroscopic lymph node and/or tumour mass
  • Maximum dimension of tumour (mm)

DissectionBack to top


Sentinel lymph node biopsy

Each individual sentinel lymph node must be examined. Each lymph node should be carefully taken from the specimen with some perinodal fat so that the afferent lymphatics and perinodal tissue can be assessed for the presence of tumour.

Lymph nodes should be sliced at 2mm intervals through the convex capsule and the hilum and along the longest meridian. 4

Submit all sections of sentinel lymph nodes for processing. Step sections through the block and immunohistochemistry are often used for the evaluation of sentinel nodes.

Regional lymph node dissection

Specimens received should be examined carefully to maximise lymph node yield. This is usually achieved by manual dissection of fixed tissue with careful examination by inspection and palpation.

Small lymph nodes, <5mm in maximum dimension, will not require dissection.

Lymph nodes > 5mm, serially section looking for grossly identifiable deposits.

Macroscopically involved lymph nodes may be bisected along the median plane to demonstrate the relationship of tumour to the capsule. One section of a macroscopically involved node is sufficient.

Where extracapsular extension is apparent or suspected, lines of dissection should extend through adjacent tissues to allow microscopic evaluation of extracapsular invasion.

The lymph node or tumour closest to the surgical margin should be so identified and sampled. 

If skin is present any abnormal area should be sampled according to the skin protocol. In the absence of any abnormality one representative block is adequate.

Axillary dissections

The axillary contents can be divided into three anatomical levels if the surgeon has marked the specimen appropriately. 4 The apical lymph node should be separately identified, if so designated by the surgeon.

Every lymph node identified should be examined histologically. The presence of matted lymph nodes or extension of tumour to edges in axillary clearance specimens is rare but should be reported if apparent to assist with radiation therapy planning.

More detail

The description of non-sentinel lymph nodes should include the location of nodes (as described by the clinician) according to the standard code.4

  • Axilla level
    • I
    • II
    • II
  • Internal mammary chain, specify interspace if provided.

Internal InspectionBack to top


Not required.

ProcessingBack to top


Sentinel lymph node specimens
  • Serially section all sentinel lymph nodes at 2mm intervals and submit all sections of each node in as few cassettes as possible. 
Regional lymph node dissection
  • Macroscopically uninvolved lymph nodes should be serially sectioned and submitted in their entirety, preferably one node in each cassette.
Macroscopically involved lymph nodes
  • Bisect perpendicularly to first dissection line and submit one representative section demonstrating relationship of tumour to capsule and the closest surgical margin if applicable. One section of each node is sufficient.

Record details of each cassette.

An illustrated block key similar to the one provided may be useful.

Block allocation key

Cassette id
Site
No. of pieces
A-C
One lymph node, trisected  
D-E
One lymph node, bisected in each cassette  
F-H
Four lymph nodes in each cassette  
I Six lymph nodes  

Acknowledgements

A/Prof Gelareh Farshid for her contribution in reviewing and editing this protocol.

ReferencesBack to top


  1. Bilous M, Reeve T, Zorbas H, Farshid G, Ahern V, Chirgwin J, Lakhani S, Pike C, Provenzano E, Salisbury E and Tan PH. Invasive breast cancer structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2012.
  2. Dahlstrom J, Coleman H, Johnson N, Salisbury E, Veness M and Morgan G. Oral structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2012.
  3. Australian Cancer Network Diagnosis and Management of Lymphoma Guidelines Working Party. Guidelines for the Diagnosis and Management of Lymphoma. The Cancer Council Australia and Australian Cancer Network, Sydney, 2005.
  4. Norris D, Ellis D, Green M, Joske D, Macardle P, Miliauskas J, Spagnolo D and Turner J. Tumours of haematopoietic and lymphoid tissue structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2010.
  5. Coventry BJ, Collins PJ, Kollias J, Bochner M, Rodgers N, Gill PG, et al. Ensuring Radiation Safety to Staff in Lymphatic Tracing and Sentinel Lymph Node Biopsy Surgery – Some Recommendations. J Nucl Med Radiat Ther. 2012;S2:008.
  6. Fitzgibbons PL, LiVolsi VA. Recommendations for handling radioactive specimens obtained by sentinel lymphadenectomy. Surgical Pathology Committee of the College of American Pathologists, and the Association of Directors of Anatomic and Surgical Pathology. Am J Surg Pathol. 2000;24(11):1549-51.