Intraoperative consultation

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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

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.

Head and neck

  • Squamous cell carcinoma - margins.
  • Thyroid nodule - diagnosis.
  • Parathyroid - confirm it is parathyroid.

Gastrointestinal tract

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

Genitourinary tract

  • Cystoprostatectomy/cystectomy - ureteral margins.

Pulmonary

  • Pneumonectomy:

Neurologic

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 and thyroid gland

Main article: 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.[9]

Checklist

  • Weight.
  • Dimensions.
  • Appearance.

Sign out

Query Parathyroid Gland:
- Hypercellular parathyroid tissue.

QUERY PARATHYROID GLAND:
- PARATHYROID GLAND.

Whipple specimen

Sign out

BILE DUCT MARGIN:
- NEGATIVE FOR MALIGNANCY.

Skin specimens

Main article: Oriented skin ellipse grossing
Main article: Unoriented skin ellipse grossing
Main article: 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.
  • 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.

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. ↑ Wong KS, Lewis JS, Gottipati S, Chernock RD (September 2014). "Utility of birefringent crystal identification by polarized light microscopy in distinguishing thyroid from parathyroid tissue on intraoperative frozen sections". Am J Surg Pathol 38 (9): 1212–9. doi:10.1097/PAS.0000000000000204. PMID 24618617.
  9. ↑ 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.
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