Comparative Analysis between Multilevel Sectioning with Conventional Haematoxylin and Eosin Staining and Immunohistochemistry for Detecting Nodal Micrometastases with Stage I and II Colorectal Cancers

  • Wong, Yin-Ping (Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Shah, Shamsul Azhar (Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Shaari, Noorsajida (Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Mohamad Esa, Mohd Shafbari (Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Sagap, Ismail (Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Isa, Nurismah Md (Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre)
  • Published : 2014.02.28


Management of patients with stage II colorectal carcinomas remains challenging as 20 - 30% of them will develop recurrence. It is postulated that these patients may harbour nodal micrometastases which are imperceptible by routine histopathological evaluation. The aims of our study were to evaluate (1) the feasibility of multilevel sectioning method utilizing haematoxylin and eosin stain and immunohistochemistry technique with cytokeratin AE1/AE3, in detecting micrometastases in histologically-negative lymph nodes, and (2) correlation between nodal micrometastases with clinicopathological parameters. Sixty two stage I and II cases with a total of 635 lymph nodes were reviewed. Five-level haematoxylin and eosin staining and one-level cytokeratin AE1/AE3 immunostaining were performed on all lymph nodes retrieved. The findings were correlated with clinicopathological parameters. Two (3.2%) lymph nodes in two patients (one in each) were found to harbour micrometastases detected by both methods. With cytokeratin AE1/AE3, we successfully identified four (6.5%) patients with isolated tumour cells, but none through the multilevel sectioning method. Nodal micrometastases detected by both multilevel sectioning and immunohistochemistry methods were not associated with larger tumour size, higher depth of invasion, poorer tumour grade, disease recurrence or distant metastasis. We conclude that there is no difference between the two methods in detecting nodal micrometastases. Therefore it is opined that multilevel sectioning is a feasible and yet inexpensive method that may be incorporated into routine practice to detect nodal micrometastases in centres with limited resources.


  1. Akagi Y, Kinugasa T, Adachi Y, Shirouzu K (2013). Prognostic significance of isolated tumor cells in patients with colorectal cancer in recent 10-year studies. Mol Clin Oncol, 1, 582-92.
  2. American Joint Committee on Cancer (2011). 7th edition of AJCC cancer staging manual.
  3. Cassidy J (2010). Guidelines for adjuvant therapy in colorectal cancer. Are they useful? And to whom? Clin Oncol, 23, 312-3.
  4. de Boer M, van Deurzen CHM, van Dijck JAAM, et al (2009). Micrometastases or isolated tumour cells and the outcome of breast cancer. N Engl J Med, 361, 653-63.
  5. Edwards BK, Ward E, Kohler BA, et al (2010). Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening and treatment) to reduce future rates. Cancer, 116, 544-73.
  6. Engstrom PF, Amoletti JP, Benson AB, et al (2009). NCCN clinical practice guidelines in oncology: colon cancer. J Natl Compr Canc Netw, 7, 778-831.
  7. Faerden AE, Sjo OH, Bukholm IR, et al (2011). Lymph node micrometastases and isolated tumor cells influence survival in stage I and II colon cancer. Dis Colon Rectum, 54, 200-6.
  8. Farshid G, Pradhan M, Kollias J, Gill PG (2000). Computer simulations of lymph node metastasis for optimizing the pathologic examination of sentinel lymph nodes in patients with breast carcinoma. Cancer, 89, 2527-37.<2527::AID-CNCR3>3.0.CO;2-6
  9. Haince JF, Houde M, Beaudry G, et al (2010). Comparison of histopathology and RT-qPCR amplification of guanylyl cyclase C for detection of colon cancer metastases in lymph nodes. J Clin Pathol, 63, 530-7.
  10. Waldman SA, Hyslop T, Schulz S, et al (2009). Association of GUCY2C expression in lymph nodes with time to recurrence and disease-free survival in pN0 colorectal cancer. JAMA, 301, 745-52.
  11. Washington MK, Berlin J, Branton P, et al (2009). Protocol for the examination of specimens from patients with primary carcinoma of the colon and rectum. Arch Pathol Lab Med, 133, 1539-51.
  12. Xi L, Coello MC, Litle VR, et al (2006). A combination of molecular markers accurately detects lymph node metastasis in non-small cell lung cancer patients. Clin Cancer Res, 12, 2484-91.
  13. Natrah MS, Ezat S, Syed MA, Rizal AM, Saperi S (2012). Quality of life in Malaysian colorectal cancer patients: a preliminary result. Asian Pac J Cancer Prev, 13, 957-62.
  14. Malaysian Society of Gastroenterology and Hepatology (2001). Screening for colorectal cancer in Malaysia. Consensus/ clinical practice guidelines.
  15. McArdle CS, McKee RF, Finlay IG, Wotherspoon H, Hole DJ (2005). Improvement in survival following surgery for colorectal cancer. Br J Surg, 95, 1008-13.
  16. Ministry of Health Malaysia (2006). Malaysia Cancer Statistics: Data and Figure Peninsular Malaysia.
  17. Nicastri DG, Doucette JT, Godfrey TE, Hughes SJ (2007). Is occult lymph node disease in colorectal cancer patients clinically significant? A review of the relevant literature. J Mol Diagn, 9, 563-71.
  18. Park SJ, Lee KY, Kim SY (2008). Clinical significance of lymph node micrometastasis in stage I and stage II colon cancer. Cancer Res Treat, 40, 75-80.
  19. Rashid MR, Aziz AF, Ahmad S, Shah SA, Sagap I (2009). Colorectal cancer patients in a tertiary referral centre in Malaysia: a five year follow-up review. Asian Pac J Cancer Prev, 10, 1163-6.
  20. Rosenberg R, Friederichs J, Gertler R, et al (2004). Prognostic evaluation and review of immunohistochemically detected disseminated tumor cells in peritumoral lymph nodes of patients with pN0 colorectal cancer. Int J Colorectal Dis, 19, 430-7.
  21. Royal College of Pathologists of Australasia (2010). Colorectal Cancer Structured Reporting Protocol.
  22. Schlimok G, Funke I, Holzmann B, et al (1987). Micrometastatic cancer cells in bone marrow: in vitro detection with anticytokeratin and in vivo labeling with anti-17-1A monoclonal antibodies. Proc Natl Acad Sci USA, 84, 8672-6.
  23. Iddings D, Ahmad A, Elashoff D, Bilchik A (2006). The prognostic effect of micrometastases in previously staged lymph node negative (N0) colorectal carcinoma: a metaanalysis. Ann Surg Oncol, 13, 1386-92.
  24. Hara M, Hirai T, Nakanishi H, et al (2007). Isolated tumor cell in lateral lymph node has no influences on the prognosis of rectal cancer patients. Int J Colorectal Dis, 22, 911-7.
  25. Hermanek P (1995). pTNM and residual tumor classifications: problems of assessment and prognostic significance. World J Surg, 19, 184-90.
  26. Hyslop T, Weinberg DS, Schulz S, Barkun A, Waldman SA (2011). Occult tumour burden predicts disease recurrence in lymph node-negative colorectal cancer. Clin Cancer Res, 17, 3292-303.
  27. Jemal A, Clegg LX, Ward E, et al (2004). Annual report to the nation on the status of cancer, 1975-2001, with a special feature regarding survival. Cancer, 101, 3-26.
  28. Joseph NE, Sigurdson ER, Hanlon AL, et al (2003). Accuracy of determining nodal negativity of colorectal cancer on the basis of the number of nodes retrieved on resection. Ann Surg Oncol, 10, 213-8.
  29. Komukai S, Nishimaki T, Watanabe H, et al (2000). Significance of immunohistochemically demonstrated micrometastases to lymph nodes in esophageal cancer with histologically negative nodes. Surgery, 127, 40-6.
  30. Lee MR, Hong CW, Yoon SN, et al (2006). Isolated tumor cells in lymph nodes are not a prognostic marker for patients with stage I and II colorectal cancer. J Surg Oncol, 93, 13-8.
  31. Linden MD, Zarbo RJ (2001). Cytokeratin immunostaining patterns of benign, reactive lymph nodes: implications for the evaluation of sentinel lymph node specimen. Appl immunohistochem Mol Morphol, 9, 297-301.

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