Difference between revisions of "Intraoperative consultation"

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[[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'''.
'''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'''.


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#Inform family ~ 8%. †
#Inform family ~ 8%. †
#Sufficient tissue? ~ 8%.
#Sufficient tissue? ~ 8%.
#Treatment planning ~ 3%.
#Treatment planning, e.g. insert a portacath ~ 3%.


Note:
Note:
Line 48: Line 49:
| 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]]
Line 92: Line 93:
| 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]]
|}
|}


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


====Pulmonary====
====Pulmonary====
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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?


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:Covers ''adnexal mass'' and ''pelvic mass''.
:Covers ''adnexal mass'' and ''pelvic mass''.


====Checklist====
General:
General:
*Specimen integrity: fragmented/intact/ruptured.
*Specimen integrity: fragmented/intact/ruptured.
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Cystic:
Cystic:
*Type: unilocular, multilocular.
*Type: unilocular, multilocular.
*Cyst content: mucinous/serous/hemorrhagic/purulent/chylous/other.
*Cyst content: mucinous/serous/hemorrhagic/purulent/chylous/other.
*Papillary excrescences: absent/present.
*Papillary excrescences: absent/present.
*Necrosis: absent/present.
*Necrosis: absent/present.
Line 165: Line 171:


Notes:
Notes:
*Mucinous versus serous:  
*Mucinous versus serous:  
**Serous: low viscosity (flows threw the grate typically seen at the bottom of sinks with ease<ref>{{Ref BITFS|33}}</ref>).
**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.
**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==

Revision as of 18:50, 19 January 2015

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

Reasons why IC are done:[1]

  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, e.g. insert a portacath ~ 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

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 endocrine pathology
Prosthetic joint query prosthetic joint infection 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.

Head and neck

  • Squamous cell carcinoma - margins.

Gastrointestinal tract

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

Genitourinary tract

  • Cystoprostatectomy/cystectomy - ureteral margins.

Pulmonary

  • Pneumonectomy:

Neurologic

Thyroid gland

  • Thyroid nodule - diagnosis.

Prosthetic joint

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 (known as read-back confirmation[4]).
  4. 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[5]).
    • Mucinous: high viscosity (jello-like consistency).

DDx

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;[6]

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:[7]

  • 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

Possibilities:

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.[8]

Checklist

  • Weight.
  • Dimensions.
  • Appearance.

Sign out

QUERY PARATHYROID GLAND:
- PARATHYROID GLAND.

Whipple specimen

Sign out

BILE DUCT MARGIN:
- NEGATIVE FOR MALIGNANCY.

See also

References

  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.
  3. URL: http://www.adasp.org/papers/position/QualityAssurance.htm. Accessed on: 2 March 2012.
  4. Nakhleh, RE. (Nov 2011). "Quality in surgical pathology communication and reporting.". Arch Pathol Lab Med 135 (11): 1394-7. doi:10.5858/arpa.2011-0192-RA. PMID 22032564.
  5. Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 33. ISBN 978-0781767798.
  6. Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 34. ISBN 978-0781767798.
  7. Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 43. ISBN 978-0781767798.
  8. Dewan, AK.; Kapadia, SB.; Hollenbeak, CS.; Stack, BC. (Dec 2005). "Is routine frozen section necessary for parathyroid surgery?". Otolaryngol Head Neck Surg 133 (6): 857-62. doi:10.1016/j.otohns.2005.05.001. PMID 16360503.