FIELD OF THE INVENTION
[001] The present invention relates to the field of medical science, and more particularly, the present invention relates to the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in India.

BACKGROUND FOR THE INVENTION:
[002] The following discussion of the background to the invention is intended to facilitate an understanding of the present invention. However, it should be appreciated that the discussion is not an acknowledgment or admission that any of the material referred to is published, known, or part of the common general knowledge in any jurisdiction as of the priority date of the application. The details provided herein the background if belongs to any publication is taken only as a reference for describing the problems, in general terminologies or principles or both of science and technology in the associated prior art.
[003] Worldwide, breast carcinoma is the commonest cancer ofwomen, with approximately 1.67 million new casesdiagnosed in the year 2012, making up for 25% of allfemale cancers. Among the most common causes ofcancer-related mortality worldwide, it ranks fifth but isthe most common cause of cancer-related mortality inless developed countries.
[004] With current treatmentregimens, almost 90% of breast cancer patients maysurvive up to 5 years. This survival is found stronglyassociated with the stage of disease at the time ofdiagnosis.The management of breast cancer can bebroadly divided into three categories- early breast cancer,locally advanced breast cancer, and metastatic breastcancer. According to NCCN guidelines patients withearly breast cancer with TNM staging T0, N1, M0, andTI-3, N0-1, and M0 should be managed according to theclinical node-negative or positive disease status. Clinicalnode negative is defined as non-palpable nodes andmammographically negative nodes in the axilla. Anypatient with the clinical node-positive disease should beevaluated with a fine needle aspiration cytology (FNAC)or core needle biopsy of the node. FNAC or core biopsy-negative nodes are considered clinically node-negative.
[005] All patients with the above TNM stage and clinical node-negative axilla should undergo an axillary staging with sentinel lymph node biopsy (SLNB).
[006] In early-stage breast cancer, the status of the axillary lymph nodes is astrong prognostic factor and SLNB is now the standard staging procedure to assess metastasis to the axillarylymph nodes.In contrast, axillary lymph node dissection(ALND) is conventional, a regular element in the surgical management of even early breast cancer. The advantages of ALND included- benefits of disease control like recurrence in the axilla and thus survival, as a prognosticprocedure and it thus helped in adjuvant treatment selection. On the downside, the lymphatic disruption caused by ALND may give rise to lymphedema, shoulderdysfunction and chronic pain due to varying degrees of nerve injury, these eventually affect the functional outcome, as well as the patient’s quality of lifenegatively. An intra-operative evaluation of SLNB withgood accuracy can help the surgeon with decision forlevel of axillary dissection (AD) and spare the morbidityof complete level III ALND or second surgicalprocedure.5 Although a histopathology of lymph nodesusing a standard hematoxylin and eosin staining (HPE) isrecommended by the American Society of ClinicalOncology guidelines, surgeons frequently request intra-operative assessment of SLNB using frozen section (FS)technique.
[007] There are some potential problems with theFS method-loss of fatty nodal tissue, interpretation ofartifact impacting and lack of standardized method for FSevaluation of SLNB. This may result in extensive inter-observer variability due to the quantity of nodal tissue examined and also due to the number of sections examined for every specimen.
[008] Evaluation of the axilla using sentinel lymph node biopsy (SLNB) is the standard of care in node-negative early breast cancer. Intraoperative assessment of SLNB with frozen section (FS) often guides the surgeon regarding the decision for level of axillary dissection.
[009] In light of the foregoing, there is a need for a prospective study on the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in Indiathat overcomes problems prevalent in the prior art.

OBJECTS OF THE INVENTION:
[010] Some of the objects of the present disclosure, which at least one embodiment herein satisfies, are as follows.
[011] The principal object of the present invention is to overcome the disadvantages of the prior art by providing a prospective study on the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in India.
[012] The object of the present invention is to provide a prospective study on the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in India, wherein the study evaluatesthe accuracy of FS of SLNB in these patients with histopathology examination (HPE) as the gold standard.
[013] Another object of the present invention is to provide a prospective study on the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in India, wherein the prospective study is designed to study the sensitivity and specificity of FSof the SLNB with HPE as the gold standard.
[014] Other objects and advantages of the present disclosure will be more apparent from the following description, which is not intended to limit the scope of the present disclosure.

SUMMARY OF THE INVENTION:
[015] The present invention relates to a prospective study on the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in India.
[016] According to one aspect of our invention, A total of 61 patients with carcinoma breast underwentsentinel lymph node (SLN) identification using 1%methylene blue dye between July 2017 and November.
[017] In another aspect of the invention, in one patient SLN is not identified, infurther five patients an in,tra-operative frozen section (FS) is not performed due to logistic reasons. These patients are excluded from the study.
[018] In another aspect of the invention, in 55 patients an intra-operative FS evaluation of theSLN is performed. All patients are female; the meanage is 53 years (range 30-84±15.09 SD).
[019] In another aspect of the invention, the agedistribution, the side of the tumor, and the quadrant distribution are shown in Table 2. The primary tumor is clinicallystaged as either T1 (23.6%) or T2 (76.4%); all patientshad clinically N0 axilla and no evidence of distantmetastasis.SLN using FS.
[020] In another aspect of the invention, the patients underwent AD upto the level of highest palpable/enlarged node if - the frozen section is diagnostic of nodal metastasis or if the surgeon found suspicious nodes during the axillary exploration; the rest of the patients underwent SLNB only.

BRIEF DESCRIPTION OF DRAWINGS:
[021] Reference will be made to embodiments of the invention, examples of which may be illustrated in accompanying figures. These figures are intended to be illustrative, not limiting. Although the invention is generally described in the context of these embodiments, it should be understood that it is not intended to limit the scope of the invention to these particular embodiments.
[022] Figure 1shows Patients in the study according toCONSORT guidelinesin accordance with the present invention.
[023] Figure 2shows the pathological T stage of the tumorin accordance with the present invention.
[024] Figure 3shows a grade of the primary tumor in accordance with the present invention.
[025] Figure 4shows aPresence of lymph vascular and perineuralinvasion in the primary tumorin accordance with the present invention.
[026] Table 1shows a two-by-two tablein accordance with the present invention.
[027] Table 2shows a baseline patient and disease detailsin accordance with the present invention.
[028] Table3shows a frozen section and histopathology details of sentinel lymph nodes (n=55)in accordance with the present invention.
[029] Table4shows thesensitivity and specificity of FS when compared to HPE in SLNBin accordance with the present invention.
[030] Table5shows a cross-tabulation of the level of axillary dissection with SLN metastatic statusin accordance with the present invention.
[031] Table6shows a comparison of the sensitivity of intra-operative frozen section of sentinel lymph nodes on the literature reviewwith the present study.in accordance with the present invention.

DETAILED DESCRIPTION OF DRAWINGS:
[032] While the present invention is described herein by way of example using embodiments and illustrative drawings, those skilled in the art will recognize that the invention is not limited to the embodiments of drawing or drawings described and are not intended to represent the scale of the various components. Further, some components that may form a part of the invention may not be illustrated in certain figures, for ease of illustration, and such omissions do not limit the embodiments outlined in any way. It should be understood that the drawings and the detailed description thereto are not intended to limit the invention to the particular form disclosed, but on the contrary, the invention is to cover all modifications, equivalents, and alternatives falling within the scope of the present invention as defined by the appended claim.
[033] As used throughout this description, the word "may" is used in a permissive sense (i.e. meaning having the potential to), rather than the mandatory sense, (i.e. meaning must). Further, the words "a" or "an" mean "at least one” and the word “plurality” means “one or more” unless otherwise mentioned. Furthermore, the terminology and phraseology used herein are solely used for descriptive purposes and should not be construed as limiting in scope. Language such as "including," "comprising," "having," "containing," or "involving," and variations thereof, is intended to be broad and encompass the subject matter listed thereafter, equivalents, and additional subject matter not recited, and is not intended to exclude other additives, components, integers, or steps. Likewise, the term "comprising" is considered synonymous with the terms "including" or "containing" for applicable legal purposes. Any discussion of documents, acts, materials, devices, articles, and the like are included in the specification solely for the purpose of providing a context for the present invention. It is not suggested or represented that any or all these matters form part of the prior art base or are common general knowledge in the field relevant to the present invention.
[034] In this disclosure, whenever a composition or an element or a group of elements is preceded with the transitional phrase “comprising”, it is understood that we also contemplate the same composition, element, or group of elements with transitional phrases “consisting of”, “consisting”, “selected from the group of consisting of, “including”, or “is” preceding the recitation of the composition, element or group of elements and vice versa.
[035] The present invention is described hereinafter by various embodiments with reference to the accompanying drawing, wherein reference numerals used in the accompanying drawing correspond to the like elements throughout the description. This invention may, however, be embodied in many different forms and should not be construed as limited to the embodiment set forth herein. Rather, the embodiment is provided so that this disclosure will be thorough and complete and will fully convey the scope of the invention to those skilled in the art. In the following detailed description, numeric values and ranges are provided for various aspects of the implementations described. These values and ranges are to be treated as examples only and are not intended to limit the scope of the claims. In addition, several materials are identified as suitable for various facets of the implementations. These materials are to be treated as exemplary and are not intended to limit the scope of the invention.
[036] The present invention relates to a prospective study on the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in India.
[037] This prospective observational study is performed atCancer Research Institute, Swami Rama HimalayanUniversity, Dehradun, India between July 2017 andNovember 2018, after an institutional ethics clearance.All carcinoma breast patients with TNM stage TI-3, N0,consent. Clinical node-negative axilla is defined as – no palpable nodes and mammographically negative nodes.
[038] The demographic and disease-related data are collectedfor the patients. At the time of definitive surgery for theprimary tumor, all patients underwent SLNB. The SLNBtissue is submitted for intra-operative FS. A grossevaluation is performed first to establish the number ofnodes and grossly suspicious nodes. All nodes aremeasured for size, nodes up to 4 mm are frozen whole,rest are bisected into half-one for FS and one preservedfor HPE. For FS, the nodes are sectioned to 4 mm widthand examined. The definition of nodal macrometastasisis–a tumor nest more than 2 mm in diameter; micrometastasisis- a tumor nest greater than 0.2 mm and less than orequal to 2 mm. The presence of extra-nodal involvement bytumor is also noted if metastases are detected. Datais collected for the presence of nodal metastasis on FS andHPE of SLNB for each patient.Statistical analysis
[039] The data is entered in MS Excel 2010 and statisticalanalysis is performed with SPSS software version 22. In one sample, the Kolmogorov-Smirnov test decided thenormality of the data sets. The Parametric tests are usedto analyze normally distributed data and non-parametric tests for non-normally distributed data. The categoricaldata areanalyzed with the Chi-square test. A two-by-twotable (Table 1) of the results of FS and HPE (gold standard)is prepared and the following formulae are used forcalculation.
? Sensitivity = A/(A + B)
? Specificity = D/(C + D)
? Accuracy = (A + D)/(A + B + C + D)
? Positive predictive value = A/(A + C)
? Negative predictive value = D/(B + D)
? False negative rate = 1-sensitivity
? False positive rate = 1-specificity
[040] A total of 61 patients with carcinoma breast underwentsentinel lymph node (SLN) identification using 1%methylene blue dye between July 2017 and November2018 (Figure 1). In one patient SLN is not identified, infurther five patients, an intra-operative frozen section (FS)is not performed due to logistic reasons. These patientsare excluded from the study.In 55 patients an intra-operative FS evaluation of theSLN is performed. All patients are female; the meanage is 53 years (range 30-84±15.09 SD). The agedistribution, the side of the tumor, and the quadrant distribution are shown in Table 2. The primary tumor is clinicallystaged as either T1 (23.6%) or T2 (76.4%); all patientshad clinically N0 axilla and no evidence of distantmetastasis.
[041] All patients underwent surgery for the primary tumor andSLN identification and intra-operative assessment of theSLN using FS. The patients underwent AD up to the levelof highest palpable/enlarged node if - the frozen sectionis diagnostic of nodal metastasis or if the surgeonfound suspicious nodes during the axillary exploration; the rest of the patients underwent SLNB only.
[042] On histopathology 20%, 76.4%, and 3.6% of patients hadT1, T2, and T3 primary tumors respectively (Figure 2);10.9%, 81.8%, and 7.3% of tumors are grade I, II and IIIrespectively (Figure 3); 34.5% tumors demonstratedlymphovascular invasion and 25.5% perineural invasion(Figure 4).
[043] A median of four SLNsis identified with a mean sizeof 13.84 mm (Table 3). On FS out of 55 patients the SLNis positive for metastasis in 14 (25.5%) patients; with 1,2, 3, and 9 SLN positive in 6, 3, 4, and 1 patient respectively. On HPE out of 55 patients the SLN ispositive for metastasis in 16 (29.1%) patients; with 1, 2,3, 4, and 9 sentinel lymph nodes positive in 5, 5, 3, 2, and1 patient respectively. The median of 2 SLNsispositive for metastasis on FS and HPE in the patientswith nodal metastasis.Table 4 shows the cross-tabulation of the FS andHPE results of SLN identified in the patients. There are13 true positive and 38 true negative results for FS,taking HPE as the gold standard test. Three patients had a false negative result and one patient had a false positiveresult. The sensitivity, specificity, positive and negativepredictive values, false negative and false positive ratesare 81.25%, 97.44%, 92.86%, 92.73%, 18.75% and2.56% respectively in this study. The false negative rateis 18.75% and false positive rate is 2.56%. Theoverall accuracy of FS of SLN in early carcinoma breastis found to be 92.73%. The 3 patients with negative FSbut positive HPE for lymph nodal metastasis in the SLNBare further analyzed and found to have onlymicrometastasis.
[044] When we looked at the level of AD performed andcompared it with the SLN metastasis, it is found that inpatients with SLN metastasis on FS 92.86% and on HPE81.25% patients underwent level III AD respectively andrest level II AD (Table 5).In patients with early breast cancer SLNB is a precisetechnique for screening the axillary lymph nodes.
[045] Moreover, a negative SLNB for metastasis can preventthe morbidity of a complete ALND.9-11 Nevertheless,current studies have questioned the need for intra-operative assessment of SLNB, especially in situationswhen complete ALND may not be done even in thepresence of metastasis in SLN. The ACOSOG Z0011study performed in patients with early breast cancerdemonstrated no difference in loco-regional diseaserecurrence in patients with 1-2 SLN metastasis, who arerandomized to either SLNB only or SLNB and ALND;with no inferior survival with the use of SLNB alonecompared with ALND in a selected patient population(i.e., patients with clinically negative axilla, tumor sizeless than 20 mm, and 1 or 2 positive nodes).
[046] In our study only 6 (10.9%) patients had 3 or more SLNmetastasis on HPE; thus, applying Z0011 criteria 89.1% of patients could potentially avoid an ALND if they all hadundergone breast-conserving surgery and received postoperative radiotherapy. Overall, in patients with negativeSLN on FS (41/55)-46.34% underwent SLNB alone,9.76% patients underwent a complete ALND, and the rest alevel II ALND (following the study criteria of intra-operative clinically suspicious enlarged nodes); inpatients with negative SLN on HPE (39/55)-48.72%underwent SLNB alone, 10.25% patients underwent acomplete ALND and rest a level II ALND in our study(Table 4). Some have even further questioned the need for any SLNB evaluation at all, suggesting that the pre-operative axillary ultrasound evaluation of nodes and fineneedle aspiration cytology (FNAC) of suspicious nodescould be enough to guide the decision regardingALND.
[047] Other concerns for the doubt regarding need for intra-operative assessment of SLNB are the different methodsused (FS vs. touch prep imprint cytology) and thequantity of tissue utilised for intra-operative assessment.A review of literature reveals various techniques forintra-operative assessment of the SLNB.
[048] Guidelinespublished by the College of American Pathologists forthe processing of SLNB focus on grossing and processingaspect of the specimen for HPE only, but there is noguideline on the preferred technique for intra-operativeassessment-either FS or touch prep.In a studypublished in 2012, 126 early breast cancer women withT1 tumors are prospectively enrolled, and 221 axillarynodes are assessed intra-operatively with FS andimprint cytology (IC). The sensitivity, specificity, andaccuracy of FS is found to be 75.7%, 100% and 91.9%;of IC is found to be 70.3%, 98.6%, and 89.1%.They found thesensitivity of FS for macrometastasis to be 83.3% and formicrometastasis to be only 40%. The specificity is100%. Inthe literature search, the sensitivity of intra-operative FS of SLNB varied from 68% to 98% formacrometastasis (Table 6), in the current study thesensitivity of 81.25% is well within this range.The large variation in the accuracy of intra-operativeassessment of SLNB reflects the different techniquesbeing employed for FS analysis. These differences intechniques include the intervals used for cutting of lymphnodes, the number of cut sections analyzed, immunohistochemistry (IHC) is used with HPE as the goldstandard for comparison, as well as the use of perioperativeIHC.The NCCN guidelines do not recommend ALNDfor only micrometastasis or isolated tumor cells on IHC.Thus, we do not see the need for diagnosing these duringan intra-operative assessment of SLNB.
[049] With the FS protocol used at our institute of bisecting allsentinel lymph nodes for FS, with 4mm sectioning ofbisected nodal tissue for FS and HPE for the rest of thebisected nodal tissue, the sensitivity and accuracy in ourstudy is 81.25%, and 92.73% respectively. An intra-operative assessment of SLNB can potentially guide thesurgical team towards the level of axillary dissection,save the morbidity of complete ALND and secondaxillary surgery.
[050] The disclosure has beendescribedwithreferencetothe accompanying embodiments herein and the various features and advantageous details thereof are explained with reference to the non-limiting embodiments in the following description. Descriptions of well-known components and processing techniques are omitted so as to not unnecessarily obscure the embodiments herein.
[051] The foregoing description of the specific embodiments so fully revealed the general nature of the embodiments herein that others can, by applying current knowledge, readily modify and/or adapt for various applications such specific embodiments without departing from the generic concept, and, therefore, such adaptations and modifications should and are intended to be comprehended within the meaning and range of equivalents of the disclosed embodiments. It is to be understood that the phraseology or terminology employed herein is for the purpose of description and not of limitation. Therefore, while the embodiments herein have been described in terms of preferred embodiments, those skilled in the art will recognize that the embodiments herein can be practiced with modification within the scope of the embodiments as described herein.

We Claim:

1) A prospective study on the role of the frozen section of a sentinel lymph node in patients with early breast cancer for the management of the axilla in India, the prospective study comprises a total of 61 patients with carcinoma breast underwent sentinel lymph node (SLN) identification using 1% methylene blue dye;
wherein the study evaluates the accuracy of FS of SLNB in these patients with histopathology examination (HPE) as the gold standard.

2) The prospective studyas claimed in claim 1, wherein in one patient SLN is not identified, in further five patients an in,tra-operative frozen section (FS) is not performed due to logistic reasons. These patients are excluded from the study.

3) The prospective study as claimed in claim 1, where in primary tumor is clinically staged as either T1 (23.6%) or T2 (76.4%); all patients had clinically N0 axilla and no evidence of distant metastasis. SLN using FS.

4) The prospective study as claimed in claim 1, whereinthe prospective study as claimed in claim 1, whereinthe patients underwent AD up-to the level of highest palpable/enlarged node if - the frozen section is diagnostic of nodal metastasis or if the surgeon found suspicious nodes during the axillary exploration; rest of the patients underwent SLNB only.

5) The prospective study as claimed in claim 1, whereinthe prospective study as claimed in claim 1, wherein an intra- operative assessment of SLNB can potentially guide the surgical team towards the level of axillary dissection, save the morbidity of complete ALND and second axillary surgery.

6) The prospective study as claimed in claim 1, whereinthe mean age is 53years (range 30-84, ± 15.09 SD), the primary tumor is clinically T1 in 23.6%, T2 in 76.4% of patients.

7) The prospective study as claimed in claim 1, whereina median of foursentinel nodes is identified, mean size of 13.84 mm. On FS SLNB is positive for metastasis in 14 (25.5%), on HPEin 16 (29.1%) patients.

8) The prospective study as claimed in claim 1, whereinthere are 13 true positives, 38 true negatives, 3 false negatives, and 1 false positive result forFS. The sensitivity, specificity, positive and negative predictive value, and false negative and false positive rates are81.25%, 97.44%, 92.86%, 92.73%, 18.75%, and 2.56% respectively in this study.

9) The prospective study as claimed in claim 1, whereinthe overall accuracy of FS of SLNBin early carcinoma breast is found to be 92.73%.