Searching for lymph nodes

[ALMD2B]

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Hi, I was just wondering what residency programs do to obtain "high" numbers of lymph nodes particularly in Colon resection specimens.

There was a horrendous discussion/argument today among attendings trying to determine where the problems are...

Other than the "squish" method, what else do residents/PA's do? (i.e Hartmann's solution)...

Thanks!

 

[AngryTesticle]

Ahh...a phenomenon that has served to torment me for months.

I've tried soaking the fat in Bouin's solution overnight. Apparently, the lymph nodes are supposed to magically appear like pop rocks. My verdict...overrated.

Basically, the way I do it is after I take whatever sections from the segment of ass, I will dissect off the fat. Then I will thinly slice the fat into strips and then squish for lymph nodes. Squishing intact fat can be frustrating and burn unnecessary ATP molecules and leave you with sore fingers. Slicing the fat prior to squishing saves me quite a bit of time. Of course, you risk cutting through the bigger lymph nodes...but then you have a bisected fat node and you submit it as such.

 

[Gene_]

AhhBasically, the way I do it is after I take whatever sections from the segment of ass, I will dissect off the fat. Then I will thinly slice the fat into strips and then squish for lymph nodes. Squishing intact fat can be frustrating and burn unnecessary ATP molecules and leave you with sore fingers. Slicing the fat prior to squishing saves me quite a bit of time. Of course, you risk cutting through the bigger lymph nodes...but then you have a bisected fat node and you submit it as such.

What he said.

 

[Pookies]

same

 

[sohsie]

I do the same. Strip the fat, then squish.

An easy way to up your lymph node count is to slice up one lymph node into many pieces and then count each slice as a lymph node. Yes, its completely unethical and dangerous for patient care since many staging classifications subclassify depending on how many lymph nodes are positive. Yet, thats most likely what is going on when various attendings boast about the lymph node counts they get.

We had an attending from another institution give a slide session and claim that their average lymph node count for a partial colectomy was 50-70 depending on the site. He said that he sends residents back who find less than 25. I guarantee you that this is what was going on, and this person is either willfully ignorant or just plain unethical.

 

[yaah]

There was a fantastic platform presentation at the USCAP where a staff member from Ball Memorial (I think) presented a study he did where starting in July he put every colon resection into two different groups (alternating between the two). Group 1 was using standard techniques (formalin fixing, etc). Group 2 used a post fixation of the fat in a solution called GEFR or something like that, can't remember, but it supposedly clears fat or highlights nodes (more like Bouins I think). It was combined with education to the residents about the importance of finding 10-12 lymph nodes, and if they didn't find them the staff person would have to come down and examine the specimen.

The results: Lymph node harvest increased from an average of I think 8 to 12. But it increased in both groups. So his conclusion was fairly obvious - educating residents helps.

Anyway, I don't have any other advice. Some people will just put through random fat and supposedly if you put through all the fat (obviously too many blocks to be routine though) you will find significant numbers of tiny, <1mm lymph nodes.

It's such a crap shoot though. Sometimes there are lots, sometimes there aren't that many. Those low anterior resections can be so tough.

 

[Mrbojangles]

I hate stripping the mesentary. I'll palpate the mesentary three times before stripping, cutting, and smushing. So there are two lymph node revealing solutions? Hartmann and Bouin? I'm not sure of the one we use but it does kind of make you high.

 

[AngryTesticle]

Anyway, I don't have any other advice. Some people will just put through random fat and supposedly if you put through all the fat (obviously too many blocks to be routine though) you will find significant numbers of tiny, <1mm lymph nodes.

It's such a crap shoot though. Sometimes there are lots, sometimes there aren't that many. Those low anterior resections can be so tough.

Yeah, when I preview slides and find that I have less than 12 lymph nodes (after previously having exhaustively examined the fat), I just go ahead and entirely submit whatever is left of the smushed fat. That way when the attending sends me "back to the bucket", I can retort, "the slides on the entirely submitted fat should be out later this afternoon! Suck on that!"

 

[Microscope Eyes]

Don't you hate it when you get a colon/rectum from a patient who had chemotherapy/radiation and there seems to be NO lymph nodes! You search and search and nothing seems to "pop" out. I had a recent case were I think I only found 6 tiny lymph nodes after 3 searches. I had another resident help me look and what he thought was lymph nodes turned out to be nothing. We must have atleast 12 lymph nodes or we are sent back to search again. The attending finally took a look herself and didn't find anything so I was off the hook. I wanted to just submit all the fat, but I knew that histology would have killed me if I would have done that.

Then you have the case like the one I did last night where the patient had colon cancer and you find a zillion lymph nodes. You can find them without even looking. They were "poping" out everywhere. Why can't all cases be that easy?

 

[DarksideAllstar]

I was informed that most pericolonic fat nodes are located immediately adjacent to the bowel wall. So what I do now is this: cut away pericolonic fat and divide it into two longitudinal strips (one that is right next to the bowel wall, and the half that is farther away). I will then meticulously search the half of fat that was adjacent to the bowel wall, then if need be I will search the other half. The last two colons I had this worked beautifully, just need to get a larger "n" to see if it will hold true. Other than that, good ole' back to the bucket with submission of multiple cassettes of squished fat, just like others had mentioned. Another resident that I was talking with has had a couple of instances where she was positive that she put submitted nodes (along with a little fat), and when the slides came out, there were none to be found. She then did levels on that block, and lo and behold two nodes popped up.
Nodes are the worst part of any specimen, except when they stick out at you like a sore thumb (ie matted together).

 

[yaah]

Looking at all these nodes can also be annoying - the ENT guy decided to do a bilateral neck dissection for a laryngeal chondrosarcoma. Apparently every malignancy behaves like squamous cell. 🙄

 

[Gut Shot]

Here's what you do: put the whole thing through. No matter how many blocks, 250, 350, 4,000, it doesn't matter. Put the whole mother F'er through. When you sit down at signout, with 114 trays of slides, be all like "I hope I got them all, I mean, I counted 1,237 nodes during preview, if you include all the random germinal centers, I hope that's adequate."

After that, no attending will screw with you in the realm of colonic lymph nodes.

 

[tardieu]

My experience has been none of the chemical treatments work well enough to make the extra effort worth it.

 

[DrBloodmoney]

Don't you hate it when you get a colon/rectum from a patient who had chemotherapy/radiation and there seems to be NO lymph nodes! You search and search and nothing seems to "pop" out. I had a recent case were I think I only found 6 tiny lymph nodes after 3 searches. I had another resident help me look and what he thought was lymph nodes turned out to be nothing. We must have atleast 12 lymph nodes or we are sent back to search again. The attending finally took a look herself and didn't find anything so I was off the hook. I wanted to just submit all the fat, but I knew that histology would have killed me if I would have done that.

Then you have the case like the one I did last night where the patient had colon cancer and you find a zillion lymph nodes. You can find them without even looking. They were "poping" out everywhere. Why can't all cases be that easy?

Got one of those cases right now. 45 minutes of mashing the fat and one 1mm lymph node to show for it. No primary tumor, just tattoo where the biopsy was taken. Patient had 7 months of neoadjuvant. The clinical history was "colon cancer."

Throw me a goddamn bone surgeon

 

[anencephalic]

Agree with the assessment of using Bouin's solution. There were a couple of other fixatives on the market a few years back that were touted to make visulization of lymph nodes easier, but in my personal experience, nothing has a higher yield than mashing the fat out.

 

[SLUsagar]

As we seem to get more Whipple's here that silicone at Oscar night, we've been told to have at least 10 pancreatic nodes on all Whipple's. This can be tough, particularly when you don't get a full Whipple but just a bit o'pancreas. Best solution I've had for these cases is to palpate all around fat surrounding pancreas, and if you find obvious nodes, first, have a few shots of your choice of liquor b/c you're damn lucky. If this does not occur, submit the fat just adjacent to pancreas. You'll be surprise to how many tiny nodes will show up.

 

[ALMD2B]

As we seem to get more Whipple's here that silicone at Oscar night, we've been told to have at least 10 pancreatic nodes on all Whipple's.

We don't seem to have a problem finding nodes for Whipple's (we use the "orange-peel method") but those colon resections.

I've used the above mentioned solutions and gained 11 nodes in a single specimen (4 --> 15 total). The solutions unfortunately give you a headache at the end of the day.

Our groups of residents/attendings are quite honest and do not slice and dice lymph nodes, hence our low count. It's a never ending battle and in the end the residents are blamed.

One of the pathologists said that she doesnt' expect first year residents to find many lymph nodes but there are no excuses for higher year residents.

 

[Doctor B.]

Unfortunately, there is no way around it: pushing fat sucks. It really slows down your grossing day but it is very important for patient care. I too have had cases that I can barely find 6 nodes. Then I've had cases where I found 35 nodes without getting sore fingers at all. It's a total crap shoot. I guess the best way to handle it is work somewhere that you don't have to gross 🙂.

 

[AngryTesticle]

Unfortunately, there is no way around it: pushing fat sucks. It really slows down your grossing day but it is very important for patient care. I too have had cases that I can barely find 6 nodes. Then I've had cases where I found 35 nodes without getting sore fingers at all. It's a total crap shoot. I guess the best way to handle it is work somewhere that you don't have to gross 🙂.

Yeah, it's a necessary but pain-in-the-ass activity. I remember asking my trainer, "so how many lymph nodes should I try to find?" or "when can i stop searching for lymph nodes?" and the answer would be, "until you've searched all the fat and found them all." Of course, I didn't like that answer but deep down inside, I knew that was the inevitable right answer keeping in mind that this is done for patient care. Still, mashing fat sucks ass.

Regarding a previous post, I agree that the worst is getting a segment of ass that has been treated with chemoradiation. Good luck finding them nodes...ha!

 

[ALMD2B]

It really slows down your grossing day but it is very important for patient care.

As for patient care, at my institution, 0/8 or 0/12 LNs in a colon resection specimen is interpreted by surgeons/oncologists as 1 positive LN and the patient is treated accordingly. This is because they think "we" the pathologists didn't look hard enough. Go figure!

 

[surg]

On this topic, I've been searching high and low and can't seem to find it (probably because while I'm reasonably facile with surgical literature, I'm a ***** when it comes to path literature), so I appeal to you all. A pathologist once told me that at some point, the standards changed from only sampling nodes >6mm to sampling any nodes. Anyone know a reference to such a standard. Is there a consensus statement now that I can reference. I'm writing a review article on the number of nodes controversy, and can't seem to get this piece down.

Thanks!

 

[yaah]

On this topic, I've been searching high and low and can't seem to find it (probably because while I'm reasonably facile with surgical literature, I'm a ***** when it comes to path literature), so I appeal to you all. A pathologist once told me that at some point, the standards changed from only sampling nodes >6mm to sampling any nodes. Anyone know a reference to such a standard. Is there a consensus statement now that I can reference. I'm writing a review article on the number of nodes controversy, and can't seem to get this piece down.

Thanks!

Not sure when the standards "changed" but you can start with

http://www.ncbi.nlm.nih.gov/entrez/..._uids=15783001&query_hl=1&itool=pubmed_docsum

Actually I would start with this one - going by my new personal rule of "when in doubt, look for things published by Neil Goldstein" because of his great ability to find trends and in things that you don't expect to have them.
http://www.ncbi.nlm.nih.gov/entrez/...t_uids=8712176&query_hl=3&itool=pubmed_DocSum

 

[surg]

That second one looks like one that I'm looking for. Thanks!

 

[Aubrey]

Another relevant Goldstein article:

http://www.ncbi.nlm.nih.gov/entrez/..._uids=11812939&query_hl=2&itool=pubmed_docsum

 

[surg]

Thanks! Guess this Goldstein guy is all over it! Any other cites that people come up with, please feel free to post them. I knew I could count on my SDN colleagues to come through in a pinch.

 

[yaah]

He's insane. He does all these studies where the data is from a 20 year period and includes like 10,000 cases and I think he looks at them all himself. He presented a platform at USCAP about microcancers arising in serrated polyps and was asked how many cases he had to look at to get the 4-5 he was presenting about. I think his answer was "thousands."