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%.
Margin status ~ 15%.
Triage tissue ~ 10%.
Inform family ~ 8%. †
Sufficient tissue? ~ 8%.
Treatment planning ~ 3%.

Note:

† Some don't consider this a good reason for an IC.^[2]

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):^[3]

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:

Identification:
- Pathology is calling - Dr. X is speaking.
- Patient identifiers - full name.
- Part(s) submitted.
Diagnosis.
Repeat of diagnosis from surgeon.
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.

Notes:

Mucinous versus serous:
- Serous: low viscosity (flows threw the grate typically seen at the bottom of sinks with ease^[4]).
- Mucinous: high viscosity, jello-like consistency.

References

↑ Zarbo, RJ.; Schmidt, WA.; Bachner, P.; Howanitz, PJ.; Meier, FA.; Schifman, RB.; Boone, DJ.; Herron, RM. (Jan 1996). "Indications and immediate patient outcomes of pathology intraoperative consultations. College of American Pathologists/Centers for Disease Control and Prevention Outcomes Working Group Study.". Arch Pathol Lab Med 120 (1): 19-25. PMID 8554440.
↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 5. ISBN 978-0781767798.
↑ URL: http://www.adasp.org/papers/position/QualityAssurance.htm. Accessed on: 2 March 2012.
↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 33. ISBN 978-0781767798.

[pmid8554440-1] Zarbo, RJ.; Schmidt, WA.; Bachner, P.; Howanitz, PJ.; Meier, FA.; Schifman, RB.; Boone, DJ.; Herron, RM. (Jan 1996). "Indications and immediate patient outcomes of pathology intraoperative consultations. College of American Pathologists/Centers for Disease Control and Prevention Outcomes Working Group Study.". Arch Pathol Lab Med 120 (1): 19-25. PMID 8554440.

[2] Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 5. ISBN 978-0781767798.

[adasp-3] URL: http://www.adasp.org/papers/position/QualityAssurance.htm. Accessed on: 2 March 2012.

[4] Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 33. ISBN 978-0781767798.

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