Intraoperative consultation

Intraoperative consultation, also quick section and frozen section, is when a surgeon requests an opinion during an operation so that they can appropriately manage a patient. It is abbreviated IC. Frozen section is often abbreviated FS.

Why intraoperative consultations are done

Reasons why IC are done:

1. Determine diagnosis & appropriate extent of operation ~ 50%.
2. Margin status ~ 15%.
3. Triage tissue ~ 10%.
4. Inform family ~ 8%. †
5. Sufficient tissue? ~ 8%.
6. Treatment planning ~ 3%.

Note:

• † Some don't consider this a good reason for an IC.

Why intraoperative consultations may be refused

• Tissue is the issue - not enough of it.
• Infectious case and no back-up cryostat.
• Management - it won't make a difference.
  • Diagnosis won't make a difference.
  • Cannot make the diagnosis.
    • Bone tumours.

Frozen section permanent section concordance

Main article: Quality

Categories by the Association of Directors of Anatomic and Surgical Pathology (ADASP):

• Agreement
• Deferral - appropriate.
• Deferral – inappropriate
  • Recommendation <=10% threshold.
• Disagreement – Minor.
• Disagreement – Major.
  • Recommendation <=3% threshold.

Common specimens

Table of common FS specimens

Specimen	Indication	Subspecialty
Pelvic mass	diagnosis	gynecologic pathology
Ovarian mass	diagnosis	gynecologic pathology
Uterine mass	diagnosis	gynecologic pathology
Sentinel lymph node	staging in vulvar melanoma	gynecologic pathology
Squamous cell carcinoma	margins	head and neck pathology
Whipple procedure	margins	gastrointestinal pathology
Liver resection (usu. metastatic disease)	margins	gastrointestinal pathology
Lower anterior resection	distal margin	gastrointestinal pathology
Cystectomy/cystoprostatectomy	ureteral margins	genitourinary pathology
Pneumonectomy (usu. cancer)	bronchus margin, lymph nodes for staging	pulmonary pathology
Brain tumour	diagnosis	neuropathology
Spinal tumour	diagnosis	neuropathology
Thyroid nodule	diagnosis	thyroid pathology
Prosthetic joint	query prosthetic joint infection	joint pathology

List of specimens

Gynecologic

• Pelvic mass - diagnosis (benign/borderline/malignant).
• Ovarian mass - diagnosis (benign/borderline/malignant).
• Uterine mass - diagnosis (benign/borderline/malignant).
• Sentinel lymph node - staging.
  • Vulvar melanoma.

Head and neck

• Squamous cell carcinoma - margins.

Gastrointestinal tract

• Whipple procedure - margins.
• Liver resection - margins.
• Lower anterior resection - distal margin.

Genitourinary tract

• Cystectomy - ureteral margins.

Pulmonary

• Pneumonectomy:
  • Bronchus - margins.
  • Lymph nodes - staging.

Neurologic

• Brain tumour - diagnosis.
• Spinal tumour - diagnosis.

Thyroid gland

• Thyroid nodule - diagnosis.

Prosthetic joint

• Query prosthetic joint infection.

Surgeon-pathologist dialog

It should include:

1. Identification:
   • Pathology is calling - Dr. X is speaking.
   • Patient identifiers - full name.
   • Part(s) submitted.
2. Diagnosis.
3. Repeat of diagnosis from surgeon.
4. Additional requests?

Specific specimens - checklists

Ovarian mass

Covers adnexal mass and pelvic mass.

General:

• Specimen integrity: fragmented/intact/ruptured.
• Dimensions: ___ x ___ x ___ cm.
• Mass: ___ grams.
• Surface involvement: absent/present.
• Consistency: solid/cystic/solid and cystic.

Cystic:

• Type: unilocular, multilocular.
• Cyst content: mucinous/serous/hemorrhagic/purulent/chylous/other.
• Papillary excrescences: absent/present.
• Necrosis: absent/present.
• Hair: absent/present.

Sections:

• Sample morphologically distinct areas - esp. solid areas, papillary excrescences.

See also

• Basics.