Difference between revisions of "Intraoperative consultation"

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Intraoperative consultation (view source)

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'''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'''.
[[Image:Tissue for frozen section in cryostat.JPG|thumb|right|Tissue within a cryostat, as seen during an intraoperative consultation. (WC/000jaw)]]
'''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==
==Why intraoperative consultations are done==
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</ref>
</ref>
#Determine diagnosis & appropriate extent of operation ~ 50%.
#Determine diagnosis & appropriate extent of operation ~ 50%.
#[[Margins|Margin]] status - 15%.
#[[Margins|Margin]] status ~ 15%.
#Triage tissue ~ 10%.
#Triage tissue ~ 10%.
#Inform family ~ 8%.
#Inform family ~ 8%. †
#Sufficient tissue? ~ 8%.
#Sufficient tissue? ~ 8%.
#Treatment planning, e.g. insert a portacath ~ 3%.
Note:
*† Some don't consider this a good reason for an IC.<ref>{{Ref BITFS|5}}</ref>


===Why intraoperative consultations may be refused===
===Why intraoperative consultations may be refused===
*Tissue is the issue - not enough of it.
*Tissue is the issue - not enough of it.
*Infectious case.
*Infectious case and no back-up cryostat.
*Management - it won't make a difference.
*Management - it won't make a difference.
**Diagnosis won't make a difference.
**Diagnosis won't make a difference.
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| Ovarian mass  
| Ovarian mass  
| diagnosis
| diagnosis
| gynecologic pathology
| [[gynecologic pathology]]
|-
|-
| Uterine mass  
| Uterine mass  
| diagnosis
| diagnosis
| gynecologic pathology
| [[gynecologic pathology]]
|-
|-
| [[Sentinel lymph node]]  
| [[Sentinel lymph node]]  
| staging in [[vulva]]r melanoma
| staging in [[vulva]]r melanoma
| gynecologic pathology
| [[gynecologic pathology]]
|-
|-
| Squamous cell carcinoma  
| [[Squamous cell carcinoma]]
| [[margins]]
| [[margins]]
| [[head and neck pathology]]
| [[head and neck pathology]]
|-
|-
| Whipple procedure  
| [[Whipple procedure]]
| margins
| margins
| [[gastrointestinal pathology]]
| [[gastrointestinal pathology]]
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| Thyroid nodule  
| Thyroid nodule  
| diagnosis
| diagnosis
| [[thyroid gland|thyroid pathology]]
| [[endocrine pathology]]
|-
|-
| Prosthetic joint
| Prosthetic joint
| query [[prosthetic joint infection]]
| query [[prosthetic joint infection]]
| [[joints|joint pathology]]
| [[joints|joint pathology]]
|-
| Parathyroid gland
| identify parathyroid gland
| [[endocrine pathology]]
|}
|}


===List of specimens===
===List of specimens===
====Gynecologic====
====Gynecologic====
*Pelvic mass - diagnosis.
*Pelvic mass - diagnosis (benign/borderline/malignant).
*Ovarian mass - diagnosis.
*Ovarian mass - diagnosis (benign/borderline/malignant).
*Uterine mass - diagnosis.
*Uterine mass - diagnosis (benign/borderline/malignant).
*[[Sentinel lymph node]] - staging.
*[[Sentinel lymph node]] - staging.
**[[Vulva]]r melanoma.
**[[Vulva]]r melanoma.
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====Head and neck====
====Head and neck====
*Squamous cell carcinoma - margins.
*Squamous cell carcinoma - margins.
*Thyroid nodule - diagnosis.
*Parathyroid - confirm it is parathyroid.


====Gastrointestinal tract====
====Gastrointestinal tract====
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====Genitourinary tract====
====Genitourinary tract====
*Cystectomy - ureteral margins.
*Cystoprostatectomy/cystectomy - ureteral margins.


====Pulmonary====
====Pulmonary====
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*[[Brain tumour]] - diagnosis.
*[[Brain tumour]] - diagnosis.
*Spinal tumour - diagnosis.
*Spinal tumour - diagnosis.
====Thyroid gland====
*Thyroid nodule - diagnosis.


====Prosthetic joint====
====Prosthetic joint====
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#* Part(s) submitted.
#* Part(s) submitted.
# [[Diagnosis]].
# [[Diagnosis]].
# Repeat of diagnosis from surgeon.
# Repeat of diagnosis from surgeon (known as ''read-back confirmation''<ref name=pmid22032564>{{Cite journal  | last1 = Nakhleh | first1 = RE. | title = Quality in surgical pathology communication and reporting. | journal = Arch Pathol Lab Med | volume = 135 | issue = 11 | pages = 1394-7 | month = Nov | year = 2011 | doi = 10.5858/arpa.2011-0192-RA | PMID = 22032564 | URL = http://www.archivesofpathology.org/doi/full/10.5858/arpa.2011-0192-RA  }}</ref>).
# Additional requests?
# Additional requests?
==Specific specimens - checklists==
===Ovarian mass===
:Covers ''adnexal mass'' and ''pelvic mass''.
====Checklist====
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.
Notes:
*‡ Mucinous versus serous:
**Serous: low viscosity (flows with ease threw the grates typically seen at the bottom of sinks<ref>{{Ref BITFS|33}}</ref>).
**Mucinous: high viscosity (jello-like consistency).
====DDx====
{| class="wikitable sortable"
! Feature
! Dx/DDx
! Notes
|-
| Unilocular cysts
| follicular cyst, epithelial cyst, very rarely [[granulosa cell tumour]] (not typically diagnosed at FS)
| no excrescences or solid areas dx = "simple cyst"; "shag carpet" appearance = serous borderline tumour
|-
| Sebaceous material ''or'' hair
| [[teratoma]]
| ''Rokitansky nodule'' present -> submit section; neuroepithelium = fleshy appearance on gross;<ref>{{Ref BITFS|34}}</ref>
''immature teratoma'' not typically diagnosed at FS
|-
| Chocolate cyst
| [[endometriosis]]
| solid elements (fibrosis vs. clear cell & endometrioid carcinoma
|}
===Endometrial carcinoma===
===General===
*Diagnosis usually known before the surgery.
*The IC revolves around whether the lesion has a "high risk" of [[lymph node metastasis]].
Factors that increase the risk of lymph node metastases:<ref>{{Ref BITFS|43}}</ref>
*Histology:
**Serous or clear cell.
**FIGO grade 3.
*Staging parameters - involvement of:
**Outer half of the myometrium.
**Uterine cervix.
**Adnexa.
===Checklist===
Gross assessment:
*Uterine cervix involvement (rare).
*Adnexal involvement (rare).
*Myometrial involvement - after sectioning bivalving and sectioning (with a 5 mm interval).
===Parathyroid gland and thyroid gland===
{{Main|Parathyroid gland}}
Possibilities:
*Parathyroid gland:
**Benign parathyroid gland.
**[[Parathyroid adenoma]]. †
**[[Parathyroid hyperplasia]]. †
**[[Parathyroid carcinoma]].
*Thyroid gland.
**Thyroid usually follicular - though parathyroid occasionally is pseudofollicular.
**Thyroid often has birefringent (calcium oxalate) crystals (60 of 80 cases) whereas parathyroid less often does (2 or 20 cases).<ref name=pmid24618617>{{cite journal |authors=Wong KS, Lewis JS, Gottipati S, Chernock RD |title=Utility of birefringent crystal identification by polarized light microscopy in distinguishing thyroid from parathyroid tissue on intraoperative frozen sections |journal=Am J Surg Pathol |volume=38 |issue=9 |pages=1212–9 |date=September 2014 |pmid=24618617 |doi=10.1097/PAS.0000000000000204 |url=}}</ref>
*[[Lymph node]].
*Fibroadipose tissue.
*[[Paraganglioma]].
Notes:
* † It is ''not'' possible to determine which one without history ''or'' all parathyroid glands.
* Surgeons are pretty good at identifying parathyroid tissue ~ 94% accurate in one series.<ref name=pmid16360503>{{Cite journal  | last1 = Dewan | first1 = AK. | last2 = Kapadia | first2 = SB. | last3 = Hollenbeak | first3 = CS. | last4 = Stack | first4 = BC. | title = Is routine frozen section necessary for parathyroid surgery? | journal = Otolaryngol Head Neck Surg | volume = 133 | issue = 6 | pages = 857-62 | month = Dec | year = 2005 | doi = 10.1016/j.otohns.2005.05.001 | PMID = 16360503 }}</ref>
====Checklist====
*Weight.
*Dimensions.
*Appearance.
====Sign out====
<pre>
Query Parathyroid Gland:
- Hypercellular parathyroid tissue.
</pre>
<pre>
QUERY PARATHYROID GLAND:
- PARATHYROID GLAND.
</pre>
===Whipple specimen===
====Sign out====
<pre>
BILE DUCT MARGIN:
- NEGATIVE FOR MALIGNANCY.
</pre>
===Skin specimens===
{{Main|Oriented skin ellipse grossing}}
{{Main|Unoriented skin ellipse grossing}}
{{Main|Grossing separately received oriented margins for a skin ellipse}}
[[Cut-up]] at frozen section depends on how the specimen is received and its size.
*Small skin specimens: the standard grossing procedure for fixed specimens.
*Large skin specimens: inking is typically as per the routine process. It is useful to mark non-margin if the nearest margin is taken [[en face margin|en face]].
*Oriented margins should be grossed in a way that allows orientation by [[ink]]. Ideally, ink should allow one to identify the different specimens. See ''[[Grossing separately received oriented margins for a skin ellipse|grossing separately received oriented margins for a skin ellipse]]''.


==See also==
==See also==
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==References==
==References==
{{Reflist|1}}
{{Reflist|2}}


[[Category:Basics]]
[[Category:Basics]]
Michael
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