lymph nodes search

[alaska82]

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Hi friends,
I am having very hard time finding lymph nodes for colectomy and gastrectomy specimens especially in post chemoradiotherapy patients. Can anyone give me tips.

 

[yaah]

Be patient. That's about the only thing you can suggest.

 

[pathstudent]

Hi friends,
I am having very hard time finding lymph nodes for colectomy and gastrectomy specimens especially in post chemoradiotherapy patients. Can anyone give me tips.

If they have had radiation the lymph nodes are as big as a half a grain of rice. I usually resorted to just putting in all the fat.

 

[KeratinPearls]

Lymph node revealing solution?

 

[KCShaw]

Practice, patience, repeat. Post-treatment cases can be difficult in that regard, because you can lose the "feel" for nodes you would otherwise have. The up side may be that there isn't a lot of extra tissue to go through, and nodes may be very concentrated in that tissue if difficult to identify. If there's not a lot of fat, I concur putting in everything is usually easiest, but if there's a lot then you just have to do the best you can and communicate with your attending about it.

Personally I despised the various enhancing/cleaning solutions for revealing nodes, again because the "feel" changed, although other residents swore by them. I swore -at- them.

 

[JPmamd09]

I struggle with it too.

Our PAs (amazing, by the way) say it comes with experience. In the meantime, I try to start out closest to the mass (if there is one visible grossly) - probably stating the obvious but just throwing it out there. After that I try sectioning fairly thinly thru the fat, squishing as I go (imagine that in a dictation). It seems that the longer something fixes the easier nodes are to find, but we don't often have that luxury. Also, isn't one of the fixatives particularly helpful for node-finding? Turns them an easier-to-appreciate shade of white?

Good luck to you. And I'd also be glad to hear advice from others.

 

[Entgegen]

While on an elective path rotation, one of the PAs showed us a method he uses for hard-to-find nodes. Take your mass of fat and, if possible, roll it up like a jelly roll (usually easier if it's a sheet-like wad of fat and fibrovascular tissue), then cut really thin slices and actually look for the nodes within the cut ends of each slice. This is usually helpful if the nodes are squishy and feel like everything else.

 

[KCShaw]

A couple of reasons I'm not a fan of sectioning through fat with a scalpel/long knife. One, I've seen way too many single nodes end up being counted as two or three nodes because they were sectioned and each fragment not properly recognized and separated at that moment. Two, you start depending more on your eyes when I think most of the time you need to depend on touch.

That said, the one or two times I did so were similar cases when there was a lot of fibrofatty crud to go through and I feared I had exhausted my own (and whoever else wandered by) ability to get anything else. It seemed to me that the hiding nodes were always in what I thought was streaky fibrofatty tissue, which was also more difficult to squish out.

Typically, I would use just my hands and a pair of slightly round-tipped scissors. I would separate the searchable tissue into small chunks, starting directly over the apparent tumor and working outward. Once you squish out all of the fat, which sometimes takes a while, there usually isn't a lot left and you may just be able to put -that- through, or resort to cautious cutting, taking care to not miss or double-count which is very easy to do when you look back at what you already sectioned one..more..time...

 

[Ombret]

Feel for nodes... then look for them... then feel for them again. You will develop this feel as you go on in your training, if you are towards the start of it. The nodes in the scenarios you mention can be tiny and we all find this challenging.

Post-fixation in a clarifying solution (people use half formalin, half alcohol or things of that nature) is frowned upon at my institution because some attendings believe that our immunostains have not been validated for this... never mind that you would almost never order immunos in this scenario (maybe a keratin), or that a node examined on H&E is much better than no node at all.

But what I really wanted to say is that the patient's head will not explode if you do not find ___ number of nodes. Your attending's head might, but they need to read what the AJCC says:

"The ongoing confusion regarding the use of the lymph node guidelines is manifest by the increased association of the X suffix along with the N category when the optimal number of lymph nodes has not been assessed. Clinicians have been reticent to assign the pN0 designation, because the lymph node count has not reached a prescribed benchmark. Both the UICC and AJCC staging references, as well as subsequent editorials, have stressed that the pN0 designation, which indicates an absence of malignant cells in the extirpated lymph node basin, can be rendered appropriately even though fewer than the optimal numbers of lymph nodes have been assessed... Accurate reporting of the number of lymph nodes removed and pathologically analyzed is mandatory and should be used as a quality indicator for both the surgeon and the pathologist. Appropriate assignation of the stage group, however, depends on the appropriate use of pN0 and not pNX. The designation pNX is appropriate only if no lymph nodes are resected or examined."

This is from http://www.cancerstaging.org/staging/PDFs/use_abuse_of_x.pdf, a useful article that also discusses the pathologist's other favorite staging term... "pMX".

So go ahead and look diligently, put in twenty cassettes of fat (our default maneuver where I work), but if you don't find twelve nodes, the patient can still be pN0.

 

[TMZ2007]

Twenty cassettes of fat? Our attendings (and histology too, I'd imagine) would flip out if we did that with any regularity. Do you get multiple levels of the fat also?

 

[Ombret]

Flip out???--they are the ones who order us to do it. Believe me, I think it's ridiculous. We are also ordered to put in 1 block/cm of grossly negative omentum for ovarian cancer staging and submit the entire endomyometrium (FULL THICKNESS) for endometrial hyperplasia. I am not joking or exaggerating.

 

[Euchromatin]

Flip out???--they are the ones who order us to do it. Believe me, I think it's ridiculous. We are also ordered to put in 1 block/cm of grossly negative omentum for ovarian cancer staging and submit the entire endomyometrium (FULL THICKNESS) for endometrial hyperplasia. I am not joking or exaggerating.

We also do 20 casettes of fat as a rough default if you find <12 good nodes on colons. None of our attendings really mind looking at extra fat - it takes like 2 seconds to slap it on the stage and glance at 2x for lymphatic tissue.

I really feel bad for you about the 1/cm on omentum, though...our attendings vary a bit but if it is grossly negative, I don't think I've heard of anyone ask for more than 5 total blocks, usually less. We use the 1/cm rule for more likely malignant lesions, like a soft tissue tumors; a large, suspicious leiomyoma if it is the only one in the uterus, etc.

I can't imagine why anyone would think full thickness sections are necessary for endometrial hyperplasia in a grossly normal uterus. Hyperplasia limited to deep foci of adenomyosis sounds pretty unlikely, and probably wouldn't have been what was seen on prior currettings. We do 1 representative full thickness section from each side and just submit the endometrium alone in that situation.

 

[pathstudent]

Flip out???--they are the ones who order us to do it. Believe me, I think it's ridiculous. We are also ordered to put in 1 block/cm of grossly negative omentum for ovarian cancer staging and submit the entire endomyometrium (FULL THICKNESS) for endometrial hyperplasia. I am not joking or exaggerating.

How about the 1cm per section for the obviously benign leiomyomata rule, especially where a woman can have 30 of them? STOOOPID!

 

[Ombret]

I really feel bad for you about the 1/cm on omentum, though...our attendings vary a bit but if it is grossly negative, I don't think I've heard of anyone ask for more than 5 total blocks, usually less. We use the 1/cm rule for more likely malignant lesions, like a soft tissue tumors; a large, suspicious leiomyoma if it is the only one in the uterus, etc.

I can't imagine why anyone would think full thickness sections are necessary for endometrial hyperplasia in a grossly normal uterus. Hyperplasia limited to deep foci of adenomyosis sounds pretty unlikely, and probably wouldn't have been what was seen on prior currettings. We do 1 representative full thickness section from each side and just submit the endometrium alone in that situation.

Yeah. I can't defend either one of these practices. For omentum, I personally think that your practice of submitting <=5 blocks is correct; there is even a paper to support that, Usubutun A. et al., Arch Pathol Lab Med 131(10): 1578–81, 2007. (They basically found that if cancer is there, it is multifocal so even one block would be enough.) Maybe someone in our department got burned by an omentum one time.

For endometrial hyperplasia, again I agree; if you cannot grossly detect tumor, the odds that there will be a T1b lesion seem pretty damned long.

And we wonder why our slide storage expenses are so high.

 

[TMZ2007]

Full thickness endomyometrium for hyperplasia? Yikes! We do endometrium only.
1/cm on obviously benign leiomyomata and omentum? Double yikes! We do like 2-3 representative sections on giant fibroids plus sampling of abnormal stuff (hemorrhage, softening, etc). We do like 2-4 cassettes on benign omentum, depending on size

I guess our grossing methods aren't nearly as tedious as I once thought...

 

[KCShaw]

Many grossing "rules" are not rules at all, but broad guideliness to help those who don't know what they're doing or are dealing with a specimen which is somehow unique.

I would be quite wary of a program which routinely puts in 20 cassettes of plain old fat for a typical colon cancer resection. Heck, a good squishing search would probably preclude the -availability- of 20 cassettes worth of fibrofatty tissue for many specimens, as it essentially eliminates all pure adipose. But don't get me wrong, there are certainly cases where finding nodes is extremely difficult and one occasionally has to resort to putting through a few cassettes of squished fibrofatty tissue which you're just not sure about, or post-treatment cases where there's a lot more fatty induration and fibrous reaction which just doesn't search or squish well and has altered the nodes themselves.

And as has been pointed out, just because there aren't many nodes doesn't mean the results of the examination are suddenly useless. It's true that some publications regarding node searches include absurd techniques resulting in large numbers of finds, but my recollection is that it boils down to if someone with experience does a conscientious search in the right area then they're going to find and submit an appropriately significant number of relevant lymph nodes. The problem is that not every resident fits that profile, and really can't early on, so I don't -entirely- blame attendings for constantly sending residents back to search for more.

 

[deleted314957]

Many grossing "rules" are not rules at all, but broad guideliness to help those who don't know what they're doing or are dealing with a specimen which is somehow unique.

I would be quite wary of a program which routinely puts in 20 cassettes of plain old fat for a typical colon cancer resection. Heck, a good squishing search would probably preclude the -availability- of 20 cassettes worth of fibrofatty tissue for many specimens, as it essentially eliminates all pure adipose. But don't get me wrong, there are certainly cases where finding nodes is extremely difficult and one occasionally has to resort to putting through a few cassettes of squished fibrofatty tissue which you're just not sure about, or post-treatment cases where there's a lot more fatty induration and fibrous reaction which just doesn't search or squish well and has altered the nodes themselves.

And as has been pointed out, just because there aren't many nodes doesn't mean the results of the examination are suddenly useless. It's true that some publications regarding node searches include absurd techniques resulting in large numbers of finds, but my recollection is that it boils down to if someone with experience does a conscientious search in the right area then they're going to find and submit an appropriately significant number of relevant lymph nodes. The problem is that not every resident fits that profile, and really can't early on, so I don't -entirely- blame attendings for constantly sending residents back to search for more.

these are a lot of classic examples of where experience trumps the "rules".

 

[alaska82]

Thank you very much for all your tips.
I got 32 lymph nodes and the surgeon emailed me congratulating me for finding them.
I love this forum. This is very usefull to me.

 

[Autopsy Sweet]

I would be quite wary of a program which routinely puts in 20 cassettes of plain old fat for a typical colon cancer resection. Heck, a good squishing search would probably preclude the -availability- of 20 cassettes worth of fibrofatty tissue for many specimens, as it essentially eliminates all pure adipose. But don't get me wrong, there are certainly cases where finding nodes is extremely difficult and one occasionally has to resort to putting through a few cassettes of squished fibrofatty tissue which you're just not sure about, or post-treatment cases where there's a lot more fatty induration and fibrous reaction which just doesn't search or squish well and has altered the nodes themselves.

In our institution it is fairly routine for us to submit additional fat (only up to about 10 cassettes) if, after submitting all possible nodes, we just don't have enough to satisfy the standard of care (e.g. 12 for colon). The purpose is not necessarily to find more nodes, because by that time the fat should have been sufficiently smashed such that no lymphoid tissue would be visibly apparent, but to demonstrate that extra effort was made to find the nodes.

Fortunately, this is a rare situation, but we've had some surgeons who have become quite angry when we didn't find the 12 and this was the only way to make them feel like we weren't just being lazy. One of the surgeons even told our department head that he doesn't get paid for the surgery if the "standard" number of lymph nodes aren't found because the insurance company deems it an insufficient tumor resection. If that's the case, I can understand the frustration. By adding the extra fat and putting it in our report we can say that we did our best and the nodes just don't exist. (But, again, this RARELY happens....)

I use the combination of cutting and smashing, always being careful to remove both halves of any node I bisect with this method so as not to count it more than once. I find that it's sometimes easier to see the smaller aggregates of lymphoid tissue on fresher tissue than it is to feel it. It's definitely time saving to spend a little extra effort to carefully examine the fat the first time and get what you need than it is to have to go bucket diving later on.

 

[KCShaw]

We would occasionally add a "few" cassettes of crud for similar reasons on occasional cases. Certainly not 20, and generally more like 5 or fewer if memory serves. Considered bad form if more than 1 or 2 tiny lymph nodes/lymphoid aggregates were found. I would be interested, however, to know if the claims of insurance not paying are accurate.

I have run across a few residents who felt they could preclude a thorough node search by simply putting in a bunch of poorly/unsearched fat to begin with. That can't fly.

 

[Gene_]

always being careful to remove both halves of any node I bisect with this method so as not to count it more than once.

All of this is so arbitrary. Does anybody believe that patients are getting betting care because somebody spent 30 minutes in finding that magical 12th lymph node? I would rather cut one in half, call it two and move on with my life. I don't because I still believe in professional ethics. Maybe things will be different in 10 years when it is money coming out of my pocket to pay a PA full time to find lymph nodes instead of doing real grossing.

 

[Enkidu]

All of this is so arbitrary. Does anybody believe that patients are getting betting care because somebody spent 30 minutes in finding that magical 12th lymph node? I would rather cut one in half, call it two and move on with my life. I don't because I still believe in professional ethics. Maybe things will be different in 10 years when it is money coming out of my pocket to pay a PA full time to find lymph nodes instead of doing real grossing.

But is it arbitrary? Why are you all doing it then? There must be some data supporting a standard of care of 12 nodes, right? Maybe someone should do a study to show that less that 12 is alright.

 

[BU Pathology]

But is it arbitrary? Why are you all doing it then? There must be some data supporting a standard of care of 12 nodes, right? Maybe someone should do a study to show that less that 12 is alright.

That study has been done and was reported in JAMA in 2007. The senior author was Birkmeyer, JAMA 2007:298, 2149, PMID 18000198

Essentially, the number of lymph nodes found at colectomy was not associated with staging, use of adjuvant chemotherapy or patient survival.

 

[lipomas]

That study has been done and was reported in JAMA in 2007. The senior author was Birkmeyer, JAMA 2007:298, 2149, PMID 18000198

Essentially, the number of lymph nodes found at colectomy was not associated with staging, use of adjuvant chemotherapy or patient survival.

Yeah but for some reason they all seem to focus on the other studies, the ones that say there is improved survival if you find >10 nodes or whatever. I can't remember the citation. Those studies are complete crap.

Lymph node clearing solutions are unhelpful in my experience. They help you find nodes which you should be able to find anyway. Unfortunately the best way to find nodes is to just be thorough. Look in the fat that has lymph nodes (in other words, don't strip the epiploic appendages and omentum and search them). Sometimes it seemed to me like dissecting a fresh specimen was most helpful, other times formalin helped.

 

[2121115]

The best way to do this is to just have an intern do it.

 

[pathstudent]

That study has been done and was reported in JAMA in 2007. The senior author was Birkmeyer, JAMA 2007:298, 2149, PMID 18000198

Essentially, the number of lymph nodes found at colectomy was not associated with staging, use of adjuvant chemotherapy or patient survival.

Unfortunately Kay Washington and the other experts who write the CAP protocol haven't read that paper and say you gotta try to find 12 and more if possible, and they say "numerous studies" show increased survival in Stage II disease with the more lymph nodes found by the surgeon and examined by the pathologist.

See page 27
http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Colon_11protocol.pdf

 

[lipomas]

Unfortunately Kay Washington and the other experts who write the CAP protocol haven't read that paper and say you gotta try to find 12 and more if possible, and they say "numerous studies" show increased survival in Stage II disease with the more lymph nodes found by the surgeon and examined by the pathologist.

See page 27
http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Colon_11protocol.pdf

To me, that is always a misinterpretation of the findings. There is probably increased survival if there are more lymph nodes found because in patients where there are more lymph nodes, the patient's immune system works better and helps fight it off.

The way that paper is interpreted, the burden of prognosis is put on the person grossing in the specimen, despite the fact that what that person is doing has occurred after the cancer has developed and after the operation and/or other treatments. They would have us believe that a careful gross dissection of the colon can add years to a patient's survival. It's asinine if you think about it. If I could cure cancer by spending 5 hours grossing a colon, I would spend 5 hours grossing a colon! Maybe they should include a line for resident grossing time in the colon cancer template if less than 15 nodes are found, just to make the non-thinkers feel better.

 

[zao275]

...despite the fact that what that person is doing has occurred after the cancer has developed and after the operation and/or other treatments. They would have us believe that a careful gross dissection of the colon can add years to a patient's survival....

Yeah, I have always had a hard time conceptualizing this in my mind. Doesn't seem to make sense.

 

[Rbrav]

I haven't pored over the literature on this, but my understanding was always that the more nodes you find, the better chance you find a positive node (if they exist), and if you can prove nodal metastasis, that will guide the patient's clinical therapy.

(This coming from someone who sucks at finding colon nodes and hates it more than anything else in grossing.)