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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 ICs are done==
==Why intraoperative consultations are done==
Reasons why IC are done:<ref>{{Cite journal  | last1 = Zarbo | first1 = RJ. | last2 = Schmidt | first2 = WA. | last3 = Bachner | first3 = P. | last4 = Howanitz | first4 = PJ. | last5 = Meier | first5 = FA. | last6 = Schifman | first6 = RB. | last7 = Boone | first7 = DJ. | last8 = Herron | first8 = RM. | title = Indications and immediate patient outcomes of pathology intraoperative consultations. College of American Pathologists/Centers for Disease Control and Prevention Outcomes Working Group Study. | journal = Arch Pathol Lab Med | volume = 120 | issue = 1 | pages = 19-25 | month = Jan | year = 1996 | doi =  | PMID = 8554440 }}
Reasons why IC are done:<ref name=pmid8554440>{{Cite journal  | last1 = Zarbo | first1 = RJ. | last2 = Schmidt | first2 = WA. | last3 = Bachner | first3 = P. | last4 = Howanitz | first4 = PJ. | last5 = Meier | first5 = FA. | last6 = Schifman | first6 = RB. | last7 = Boone | first7 = DJ. | last8 = Herron | first8 = RM. | title = Indications and immediate patient outcomes of pathology intraoperative consultations. College of American Pathologists/Centers for Disease Control and Prevention Outcomes Working Group Study. | journal = Arch Pathol Lab Med | volume = 120 | issue = 1 | pages = 19-25 | month = Jan | year = 1996 | doi =  | PMID = 8554440 }}
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#Determine diagnosis & appropriate extent of operation ~ 50%.
#Determine diagnosis & appropriate extent of operation ~ 50%.
#Margins 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===
*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 ==
==Frozen section permanent section concordance ==
{{Main|Quality}}
{{Main|Quality}}


Categories by ADASP:<ref>URL: [http://www.adasp.org/papers/position/QualityAssurance.htm http://www.adasp.org/papers/position/QualityAssurance.htm]. Accessed on: 2 March 2012.</ref>
Categories by the ''Association of Directors of
Anatomic and Surgical Pathology'' (ADASP):<ref name=adasp>URL: [http://www.adasp.org/papers/position/QualityAssurance.htm http://www.adasp.org/papers/position/QualityAssurance.htm]. Accessed on: 2 March 2012.</ref>
*Agreement
*Agreement
*Deferral - appropriate.
*Deferral - appropriate.
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==Common specimens==
==Common specimens==
Gynecologic:
===Table of common FS specimens===
*Pelvic mass - diagnosis.
{| class="wikitable sortable"
*Ovarian mass - diagnosis.
! Specimen
*Uterine mass - diagnosis.
! Indication
*Sentinel lymph node - staging.
! Subspecialty
|-
| Pelvic mass
| diagnosis
| [[gynecologic pathology]]
|-
| Ovarian mass
| diagnosis
| [[gynecologic pathology]]
|-
| Uterine mass
| diagnosis
| [[gynecologic pathology]]
|-
| [[Sentinel lymph node]]
| staging in [[vulva]]r 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
| [[endocrine pathology]]
|-
| Prosthetic joint
| query [[prosthetic joint infection]]
| [[joints|joint pathology]]
|-
| Parathyroid gland
| identify parathyroid gland
| [[endocrine 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.
**[[Vulva]]r melanoma.
**[[Vulva]]r melanoma.


Head and neck:
====Head and neck====
*Squamous cell carcinoma - margins.
*Squamous cell carcinoma - margins.


Gastrointestinal tract:
====Gastrointestinal tract====
*Whipple procedure - margins.
*Whipple procedure - margins.
*Liver resection - margins.
*Liver resection - margins.
*Lower anterior resection - distal margin.
*Lower anterior resection - distal margin.


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


Pulmonary:
====Pulmonary====
*Pneumonectomy:
*Pneumonectomy:
**Bronchus - margins.
**Bronchus - margins.
**Lymph nodes - staging.
**[[Lymph nodes]] - staging.


Neurologic:
====Neurologic====
*Brain tumour - diagnosis.
*[[Brain tumour]] - diagnosis.
*Spinal tumour - diagnosis.
*Spinal tumour - diagnosis.


Thyroid gland:
====Thyroid gland====
*Thyroid nodule - diagnosis.
*Thyroid nodule - diagnosis.


Prosthetic joint:
====Prosthetic joint====
*Query [[prosthetic joint infection]].
*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 (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?
==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===
{{Main|Parathyroid gland}}
Possibilities:
*Parathyroid gland: †
**Benign parathyroid gland.
**[[Parathyroid adenoma]].
**[[Parathyroid hyperplasia]].
**[[Parathyroid carcinoma]].
*Thyroid gland.
*[[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:
- PARATHYROID GLAND.
</pre>
===Whipple specimen===
====Sign out====
<pre>
BILE DUCT MARGIN:
- NEGATIVE FOR MALIGNANCY.
</pre>


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


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