False-Negative Interpretation of Breast Sentinel Lymph Node Touch Preps: Analysis of the Causes with Suggestions to Improve Diagnostic Accuracy

Frank Chen, MD, PhD, MBA, David Hicks, MD, Maria Nava, MD, Richard Cheney, MD


Sentinel lymph node (SLN) biopsy has become widely accepted as an important procedure in staging breast cancer. False-negative results of touch prep (TP) examination at time of SLN biopsy requires additional surgery, delaying treatment and increasing cost. Therefore, we have analyzed our experience with false-negative interpretation on SLN TP’s. Eight-hundred and three consecutive SLN biopsies from 2003 to 2005 were obtained from the pathology archive of Roswell Park Cancer Institute. The intraoperative consultation results were correlated with the final diagnoses.  Twenty-five SLN intraoperative consultations had false-negative TP’s [false-negative rate = 3.1% (25/803), including 9 metastatic lobular carcinomas and 16 metastatic ductal carcinomas]. These cases were re-evaluated by 3 pathologists independently, and the metastases in the SLN sections were confirmed by positive cytokeratin staining.  Size of the metastatic focus, nuclear grade and the adequacy of TP’s were analyzed with regard to the cause of false-negative results. On re-screening of TP’s, we found that rare tumor cells of low nuclear grade were identified on 28% (7/25) of the TP’s (3 metastatic lobular carcinomas and 4 metastatic ductal carcinomas). In the remaining 72% (18/25) of TP’s, re-screening revealed no evidence of tumor.  Evaluation of these TP’s demonstrated that 50% (9/18) were unsatisfactory for evaluation or limited by scant cellularity. While cases that remained negative on re-screening tended to have smaller measured foci of tumor in the SLN (Average 0.65 mm vs. 0.94 mm from cases that were positive on re-screening), there was considerable overlap between these two groups. In conclusion, TP’s with scant cellularity, unsatisfactory TP’s and failure to identify tumor cells with low nuclear grade were found to significantly contribute to false-negative interpretations. We suggest that an additional TP or frozen section may be necessary if the cellularity of the initial TP is limited.  Correlation with the original core biopsy may be of value to help in identifying cancer cells of low nuclear grade. 


sentinel lymph node, breast cancer, false-negative interpretation

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Bleiweiss IJ. Sentinel lymph nodes in breast cancer after 10 years: rethinking basic principles. Lancet Oncol. 2006;7(8):686-692.

Lyman GH, Temin S, Edge SB, et al. Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2014;32(13):1365-1383.

Guidroz JA, Johnson MT, Scott-Conner CE, De Young BR, Weigel RJ. The use of touch preparation for the evaluation of sentinel lymph nodes in breast cancer. Am J Surg. 2010;199(6):792-796.

Vanderveen KA, Ramsamooj R, Bold RJ. A prospective, blinded trial of touch prep analysis versus frozen section for intraoperative evaluation of sentinel lymph nodes in breast cancer. Ann Surg Oncol. 2008;15(7):2006-2011.

Kamath VJ, Giuliano R, Dauway EL, et al. Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection. Arch Surg. 2001;136(6):688-692.

Pugliese MS, Kohr JR, Allison KH, Wang NP, Tickman RJ, Beatty JD. Accuracy of intraoperative imprint cytology of sentinel lymph nodes in breast cancer. Am J Surg. 2006;192(4):516-519.

Kane JM III, Edge SB, Winston JS, Watroba N, Hurd TC. Intraoperative pathologic evaluation of a breast cancer sentinel lymph node biopsy as a determinant for synchronous axillary lymph node dissection. Ann Surg Oncol. 2001;8(4):361-367.

Forbes RC, Pitchford C, Simpson JF, Balch GC, Kelley MC. Selective use of intraoperative touch prep analysis of sentinel nodes in breast cancer. Am Surg. 2005;71(11):955-960; Discussion 961-962.

Thor A. A revised staging system for breast cancer. Breast J. 2004;10 (Suppl 1):S15-S18.

Treseler P. Pathologic examination of the sentinel lymph node: what is the best method? Breast J. 2006;12 (5 Suppl 2):S143-S151.

Pendas S, Dauway E, Cox CE, et al. Sentinel node biopsy and cytokeratin staining for the accurate staging of 478 breast cancer patients. Am Surg. 1999;65(6):500-505; discussion 505-506.

Johnston EI, Beach RA, Waldrop SM, Lawson D, Cohen C. Rapid intraoperative immunohistochemical evaluation of sentinel lymph nodes for metastatic breast carcinoma. Appl Immunohistochem Mol Morphol. 2006;14(1):57-62.

Beach RA, Lawson D, Waldrop SM, Cohen C. Rapid immunohistochemistry for cytokeratin in the intraoperative evaluation of sentinel lymph nodes for metastatic breast carcinoma. Appl Immunohistochem Mol Morphol. 2003;11(1):45-50.

Celebioglu F, Sylvan M, Perbeck L, Bergkvist L, Frisell J. Intraoperative sentinel lymph node examination by frozen section, immunohistochemistry and imprint cytology during breast surgery--a prospective study. Eur J Cancer. 2006;42(5):617-620.


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