title: Sentinel node biopsies in melanoma patients: a protocol for accurate, efficient, and cost-effective analysis by preselection for immunohistochemistry on the basis of Tyr-PCR.
abstract: BACKGROUND
  Immunohistochemistry (IHC) of serial sectioning is considered the gold standard for detection of melanoma activity in sentinel node (SN) biopsies. However, this is cost and labor intensive. In contrast, tyrosinase reverse transcription-polymerase chain reaction (RT-PCR) is simple and quick, but it is hampered by its extreme sensitivity. This study was performed to test whether a strategy that combines the two methods, using tyrosinase RT-PCR to preselect nodes for IHC, could be accurate and cost effective.
  
  
  METHODS
  In 36 patients, SNs were identified by scintigraphy and patent blue uptake. Of each SN, one cross section was analyzed first by hematoxylin and eosin staining. Next, all nodes were examined by serial sectioning and IHC of one-half and tyrosinase RT-PCR of the other. Before comparison, all results were documented in a blinded manner. Material costs and workload estimates were noted per SN.
  
  
  RESULTS
  Fifty-five SNs were retrieved from the 36 patients. Hematoxylin and eosin staining of the first cross section revealed tumor positivity in 3 patients (6 SN). Tyrosinase RT-PCR was positive in 11 of the remaining 33 patients (19 of 49 SN). Of these same 11 patients, only 5 were shown to have tumor-positive SNs by using IHC on serial sections (7 SN). All these nodes had been positive for tyrosinase on PCR. For IHC, an average of 40 sections were prepared and examined per SN at a cost of $200(U.S.)/SN. In contrast, routine tyrosinase RT-PCR costs $37(U.S.)/SN, and takes 5% of the time necessary for IHC. A strategy including hematoxylin and eosin staining on the first cross section, followed by tyrosinase RT-PCR on half of each negative (half) node, could preselect nodes to be taken through serial sectioning. In these series, such a strategy would have prevented serial sectioning and IHC of 30 SN from 22 patients. Apart from a considerable gain in efficiency, this would have reduced material costs by a minimum of $6000 (U.S.). This discrepancy would be even higher if work intensity of analysts and pathologists were considered.
  
  
  CONCLUSIONS
  In routine analysis of SN biopsies in melanoma patients, tyrosinase RT-PCR can be used effectively to preselect nodes for further IHC of serial sections. This method seems both time and cost effective.
authors.affiliation: Department of Surgery, University Hospital, Utrecht, The Netherlands.
authors.forename: D
authors.initials: D
authors.lastname: van der Velde-Zimmermann
authors.forename: M E
authors.initials: ME
authors.lastname: Schipper
authors.forename: R A
authors.initials: RA
authors.lastname: de Weger
authors.forename: A
authors.initials: A
authors.lastname: Hennipman
authors.forename: I H
authors.initials: IH
authors.lastname: Borel Rinkes
mesh_terms: D001706:Biopsy / Q000191:economics / Q000379:methods*; D003362:Cost-Benefit Analysis; D006801:Humans; D007150:Immunohistochemistry / Q000191:economics / Q000379:methods; D008197:Lymph Node Excision / Q000379:methods; D008198:Lymph Nodes / Q000000981:diagnostic imaging / Q000473:pathology*; D008207:Lymphatic Metastasis; D008545:Melanoma / Q000000981:diagnostic imaging / Q000473:pathology* / Q000556:secondary* / Q000601:surgery; D009426:Netherlands; D011446:Prospective Studies; D011877:Radionuclide Imaging; D015203:Reproducibility of Results; D020133:Reverse Transcriptase Polymerase Chain Reaction / Q000191:economics; D012878:Skin Neoplasms / Q000473:pathology