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    Sentinel and regional lymph nodes -melanoma

    Background

    Lymph nodes are common components of radical resections for malignancies. Sentinel lymph node excision1 and lymph node dissections are undertaken to assess extent of regional node tumour metastases.

    This protocol includes sentinel lymph node biopsy and regional lymph node dissections for melanoma. Separate protocols are provided for neck dissections and breast cancer 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.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.2
    • 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 Inspection

    Orientate and identify the anatomical features of the specimen.

    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.

    • Sentinel lymph node
    • Regional lymphadenectomy/lymph node dissection (see separate protocol for neck dissection)
    • Other, describe

    Specimen site2

    • Groin
    • Axilla
    • Other, describe

    Specimen description

    • Specimen size in three dimensions (mm)1
    • Radioactive count if known4
    • Uptake of dye4
      • 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

    • Orientation marker
      • No
      • Yes, describe
    • Specimen size in three dimensions (mm)1
    • Number of lymph nodes3,4
    • Range of maximum diameters (mm)
    • Largest macroscopically involved lymph node and/or matted tumour mass, if present
      • Maximum dimension of tumour (mm)
    • Macroscopic extranodal tumour
      • Absent
      • Present, describe
      • Distance from surgical soft tissue margin (mm)
      • Distance from apex/apical node (mm)
      • Infiltration of vessels, nerves, skeletal muscle or other adjacent structures

    Dissection

    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.2

    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.

    In current practice there is wide variation in how lymph nodes from regional lymphadenectomies are dissected and processed and the methods described below should only be considered as a guide.

    Specimens should be examined carefully to maximise lymph node yield. Each lymph node must be blocked, examined and recorded in such a way so as to enable accurate measurement of lymph node numbers and involvement at microscopic examination. This is usually achieved by manual dissection of fixed tissue with careful examination by inspection and palpation.

    Small lymph nodes, <5mm in maximum dimension, usually will not require dissection and can be submitted whole.

    Lymph nodes > 5mm, serially section at 2mm intervals looking for grossly identifiable deposits.7

    Please note that some institutions serially section all lymph nodes at 2mm whether for sentinel node analysis or for routine regional lymph node evaluation with the entire lymph node submitted for histological evaluation.8

    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.9,10 If extranodal tumour is close to the surgical soft tissue margin, the margin may be painted with ink. If oriented specify the margin.

    If skin is present, identify and sample the previous biopsy track if possible. Any abnormal area should be sampled according to the skin protocol. In the absence of any abnormality one representative block is adequate.

    If skin is present, identify and sample the previous biopsy track if possible. Any abnormal area should be sampled according to the skin protocol. In the absence of any abnormality one representative block is adequate.

    Every lymph node identified should be examined histologically. The presence of matted lymph nodes or extension of tumour to specimen edges is rare but should be reported if apparent to assist with radiation therapy planning.9,10

    The description of non-sentinel lymph nodes should include the location of nodes (as described by the clinician) according to the standard code.3

    The axillary contents can be divided into three anatomical levels if the surgeon has marked the specimen appropriately.3,4 The apical lymph node should be separately identified, if so designated by the surgeon.

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

    Groin

    • Other, specify
    • Iliac
    • Femoral
    • Inguinal

    Internal Inspection

    Not required.


    Processing

    • Serially section all sentinel lymph nodes at 2mm intervals and submit all sections of each node in as few cassettes as possible.
    • Macroscopically uninvolved lymph nodes > 5 mm n max. dimension should be serially sectioned and submitted in their entirety, preferably one node in each cassette.
    • Lymph nodes <5mm in max. dimension can be submitted whole and more than one can be included in each cassette
    • 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

    Dr Craig James for his contribution in reviewing and editing this protocol.


    References

    1. 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.
    2. 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.
    3. Ramsay A, Attygale A, Menon G, Naresh K and Wilkins B. Tissue pathways for lymph node, spleen and bone marrow trephine biopsy specimens, The Royal College of Pathologists, London, 2008.
    4. Farshid G, Ahern V, Chirgwin J, Lakhani S, Pike C, Provenzano E, et al. Invasive breast cancer structured reporting protocol. 2nd ed. Surry Hills, NSW: The Royal College of Pathologists of Australasia, 2012.
    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.
    7. Slater D, Walsh M. Dataset for the histological reporting of primary cutaneous malignant melanoma and regional lymph nodes. 3rd ed. London: The Royal College of Pathologists; 2014.
    8. Frishberg DP, Balch C, Balzer BL, Crowson AN, Didolkar M, McNiff JM, et al. College of American Pathologists Protocol for the examination of specimens from patients with melanoma of the skin. Arch Pathol Lab Med. 2009;133(10):1560-7.
    9. Sahoo S, Lester SC. Pathology of Breast Carcinomas After Neoadjuvant Chemotherapy: An Overview With Recommendations on Specimen Processing and Reporting. Archives of Pathology & Laboratory Medicine. 2009;133(4):633-42.
    10. Australian Cancer Network Melanoma Guidelines Revision Working Party. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand, Cancer Council Australia and Australian Cancer Network, Sydney and New Zealand Guidelines Group, Wellington, 2008.

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      Breast axilla 1

      Axillary regional resection

      Breast axilla 2

      Lymph nodes retrieved from an axillary resection, see block key

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      26-Mar-2019
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