Intraoperative consultation
Jump to navigation
Jump to search
The printable version is no longer supported and may have rendering errors. Please update your browser bookmarks and please use the default browser print function instead.
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, 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
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 | 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.
- Vulvar melanoma.
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:
- 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 (known as read-back confirmation[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
Main article: 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.[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
- ↑ 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.
- ↑ 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.
- ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 33. ISBN 978-0781767798.
- ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 34. ISBN 978-0781767798.
- ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 43. ISBN 978-0781767798.
- ↑ 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.