Frozen Pathology Research Articles

Spontaneous cystic artery bleed presenting as hemoperitoneum and possible gallbladder cancer

Presenter: Karolin Ginting MD | The Jewish Hospital Background: Hemoperitoneum secondary to spontaneous rupture of cystic artery is extremely rare. When present, it is usually due to malignancy or ruptured pseudoaneurysm. Prompt intervention to control the hemorrhage and multidisciplinary evaluation for etiology is essential. Methods: We report a rare case of hemoperitoneum secondary to spontaneous rupture of cystic artery. The patient initially presented with acute onset abdominal pain. Imaging performed in the emergency department revealed large right upper quadrant hematoma with active extravasation, hemoperitoneum, and gallbladder mass. He underwent emergent embolization of the cystic artery. Follow-up work-up to elucidate the cause of bleeding included magnetic resonance cholangiopancreatography (MRCP), esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) with biopsy. This showed a large gallstone, as well as possible solid tumor in the lumen of the gallbladder versus hematoma. Patient was discharged home with plans to follow up with us (surgical oncologist). However, three weeks later patient re-presented with acute onset abdominal pain and leukocytosis. Repeat imaging showed near resolution of right upper quadrant hematoma, extensive thickening of the gallbladder wall, pericholecystic stranding and omental masses. The patient consented for cholecystectomy, possible liver resection and lymphadenectomy. Results: Patient underwent diagnostic laparoscopy without any obvious evidence of metastatic disease. Frozen pathology on a small liver nodule came back as bile duct hamartoma. There were omental adhesions to gallbladder and on release of adhesions, a perforated gallbladder was noted. Three stones in right upper quadrant were initially noted but later on elevating the omentum, numerous gallstones throughout the omentum and lower pelvis were found. This explained the findings on the CT scan which were concerning for carcinomatosis. Robotic platform immensely helped to avoid conversion to open procedure. Indocyanine green (ICG) firefly imaging was used to identify cystic duct and common bile duct. Additionally, firefly imaging delineated the plane between gallbladder and liver bed. The gallbladder was removed and sent to pathology for review, which was grossly negative for cancer. All noted stones were meticulously retrieved and extracted from the abdominal cavity. The patient's postoperative course was unremarkable, and he was discharged home the next day. Final pathology showed chronic cholecystitis with bile duct hamartomas. Conclusion: Initial non-operative management of hemoperitoneum secondary to cystic artery rupture via emergent angioembolization is feasible. This is a temporary step to allow complete workup for malignancy and operative planning for interval cholecystectomy. Robotic surgery platform is very useful for difficult gallbladder procedures.

1138 Repeat Laparoscopy for Pregnancy of Unknown Location

Video Objective To demonstrate the importance of total salpingectomy when surgical management of ectopic pregnancy is warranted. Setting The patient is a 41 year old G6P4014 at 6 weeks gestation who presented with abdominal pain and vaginal bleeding. She underwent an initial dilation and curettage and bilateral salpingectomy for pregnancy of unknown location (PUL). Pathology returned without evidence of pregnancy tissue. Interventions The patient required additional imaging including a transvaginal ultrasound and magnetic resonance imaging scan. She underwent repeat surgical intervention with removal of the remaining portion of the right fallopian tube and intra-operative frozen pathology to confirm the diagnosis and definitive treatment of the ectopic pregnancy. Conclusion This is a unique case where initial surgical management failed to identify a pregnancy of unknown location. In the setting of a suspected tubal ectopic pregnancy requiring salpingectomy, performing a complete salpingectomy is essential. Additionally, the use of intra-operative frozen pathology can aid in confirming the diagnosis and successful treatment of a PUL.

Slide-free imaging of hematoxylin-eosin stained whole-mount tissues using combined third-harmonic generation and three-photon fluorescence microscopy.

Intraoperative margin assessment of surgical tissues during cancer surgery is clinically important, especially in the case of tissue conserving surgery like Mohs micrographic surgery in which minimization of the surgical area is considered crucial. Frozen pathology is the gold standard of assessing excised tissues for signs of remaining cancerous lesions. The current protocol, however, is time-consuming and labor-intensive. Instead of the complex frozen sectioning, staining, and traditional white light microscopy imaging protocol, optically sectioned histopathological imaging of hematoxylin-eosin stained whole-mount skin tissues with a subfemtoliter resolution is demonstrated by using nonlinear microscopy in this study. With our proposed method, the reagents of staining and the contrast of imaging are fully consistent with the current clinical standard of frozen pathology, thus facilitating rapid intraoperative assessment of surgical tissues for future applications. Image: Slide-free nonlinear microscopy imaging of H&E stained whole-mount skin tissue showing the morphology of sweat glands.

Diagnosis and Clinical Analysis of Primary Thyroid Lymphoma.

Objective To summarize our experiences in the diagnosis and prognosis of different subtypes of primary thyroid lymphoma (PTL). Methods The clinical data of 27 PTL patients who were treated in our hospital from January 1998 to December 2014 were retrospectively analyzed. The pathological types of these patients included B cell lymphoma unclassifiable (BCLU) (n=5),mucosa-associated lymphiod tissue lymphoma (MALT) (n=9),diffuse large B cell lymphoma (DLBCL) (n=12),and T cell lymphoma (n=1). Results Of all these 27 cases,the most common clinical symptom was painless swelling of the neck (n=21,77.8%). Of 7 patients who had received preoperative fine needle biopsy,lymphoma was suspected in 2 cases (28.6%). Among these 7 cases,the positive rate of suspicious lymphoma was 66.7% in 3 DLBCL patients,0 in 3 MALT patients,and 0 in 1 BCLU paitent. Also,25 patients underwent intraoperative frozen pathological examination,which revealed lymphoma or suspicious lymphoma in 16 cases (64.0%); in these patients,the positive rate was 66.7% for BCLU,77.8% for MALT,58.3% for DLBCL,and 0 for T-cell lymphomas. The overall survival was (89.3±12.4) months,and the overall 5-year survival rate was 61.6%. The estimated survival in symptomatic group was 31.6 months,which was significantly shorter than that in asymptomatic group (97.9 months) (P=0.032). Other factors including age,sex,tumor size,tumor stage,international prognostic index,tracheal compression,lactate dehydrogenase,residual tumor,and pathological type showed no significant effect on survival(all P>0.05). Conclusions DLBCL has the highest fine needle biopsy positive rate,MALT has the highest frozen pathological positive rate,and intraoperative frozen pathology has more malignant results than the preoperative fine needle biopsy in the diagnosis. The accompanying lymphoma symptoms may be an adverse prognostic factor.

Percutaneous CT-guided needle biopsies of musculoskeletal tumors: a 5-year analysis of non-diagnostic biopsies.

To study non-diagnostic CT-guided musculoskeletal biopsies and take steps to minimize them. Specifically we asked: (1) What malignant diagnoses have a higher non-diagnostic rate? (2) What factors of a non-diagnostic biopsy may warrant more aggressive pursuit? (3) Do intra-procedural frozen pathology (FP) or point-of-care (POC) cytology reduce the non-diagnostic biopsy rate? This study was IRB-approved and HIPAA-compliant. We retrospectively reviewed 963 consecutive CT-guided musculoskeletal biopsies. We categorized pathology results as malignant, benign, or non-diagnostic and recorded use of FP or POC cytology. Initial biopsy indication, final diagnosis, method of obtaining the final diagnosis of non-diagnostic biopsies, age of the patient, and years of biopsy attending experience were recorded. Groups were compared using Pearson's χ(2) test or Fisher's exact test. In all, 140 of 963 (15%) biopsies were non-diagnostic. Lymphoma resulted in more non-diagnostic biopsies (P < 0.0001). While 67% of non-diagnostic biopsies yielded benign diagnoses, 33% yielded malignant diagnoses. Patients whose percutaneous biopsy was indicated due to the clinical context without malignancy history almost always generated benign results (96%). Whereas 56% of biopsies whose indication was an imaging finding of a treatable lesion were malignant, 20% of biopsies whose indication was a history of malignancy were malignant. There was no statistically significant difference in the nondiagnostic biopsy rates of pediatric versus adult patients (P = 0.8) and of biopsy attendings with fewer versus more years of experience (P = 0.5). The non-diagnostic rates of biopsies with FP (8%), POC cytology (25%), or neither (24%) were significantly different (P < 0.0001). Lymphoma is the malignant diagnosis most likely to result in a non-diagnostic biopsy. If the clinical and radiologic suspicion for malignancy is high, repeat biopsy is warranted. If the clinical context suggests a benign lesion, a non-diagnostic biopsy may be considered reassuring. Frozen pathology may decrease the non-diagnostic biopsy rate.

Application of preoperative CT-guided Hook-wire localization of pulmonary nodules in thoracoscopic lobectomy of lung

Objective To evaluate the application of preoperative CT-guided Hook-wire localization of pulmonary nodules in thoracoscopic lobectomy of lung. Method Twenty eight patients with 31 pulmonary nodules of ground-glass opacity (GGO) detected by CT scan were admitted in our hospital from December 2008 to December 2013, including 17 males and 11 females with an average age of 55. The lesions were located by CT-guided Hook-wire technique, and lobectomy plus lymphadenectomy or pulmonary wedge resection were performed according to the results of fast frozen pathology. The characteristics of pulmonary nodules and general condition of the patients were analyzed. Results Among 31 nodules, 19 were malignant and 12 benign with an average size of (1.8±0.6) cm and thickness of (1.2±0.4) cm. The vertical distance from pleural to nodules was (1.5±0.7) cm and the insert depth of needle was (2.5±0.9) cm. The time for CT-guided Hook-wire localization was (16.5±5.2) min. The operation time for pulmonary wedge resection and pulmonary lobectomy was (18.5±5.5) min and (54.7±12.5) min, respectively. Intraoperative frozen section showed malignant tumors in 18 patients (19 GGO nodules), lobectomy plus lymphadenectomy were performed in 16 cases; 2 patients did not undergo pulmonary lobectomy because of poor physical condition or 2 GGO nodules in different lobes. There were no operation complications in this series. Postoperative pathologic findings of 31 nodules showed 9 cases of adenocarcinoma, 10 bronchioloalveolar carcinoma, 5 atypical adenomatous hyperplasia, 2 epithelioid hemangioendothelioma, 2 chronic inflammation, 1 hamartoma, 1 inflammatory pseudotumor and 1 sarcoidosis. The average postoperative hospital stay was (6.6±1.9) days. Conclusions Endoscopic resection of pulmonary GGO nodules with CT-guided Hook-wire localization technique is feasible and safe, with less complications and less time consuming. Key words: Surgery, computer-assisted; Tomography, X-ray computed; Solitary pulmonary nodule; Hook-wire; Ground-glass opacity

Surgical Treatment of Hashimoto's with Thyroid Microcarcinoma.

The aim of this study is to explore the surgical strategies for treating Hashimoto's disease complicated with thyroid microcarcinoma. We analyzed the clinical data of 25 patients with Hashimoto's disease with thyroid microcarcinoma who were treated in our hospital from January 1995 to September 2011. The incidence of Hashimoto's disease with thyroid microcarcinoma was 9.8 % (25/256) in our hospital. Amongst them, 19 patients had papillary thyroid carcinoma and six had follicular thyroid carcinoma. There were 24 cases (96 %) confirmed by the frozen section examination and one (4 %) after surgery. One patient did not undergo remedial surgery. The surgical approaches were determined based on preoperative examinations and intraoperative frozen pathology, including thyroid lobe and isthmus resection with contralateral lobe subtotal resection in 19 cases, and bilateral subtotal thyroid lobectomy in one case. Central lymph node dissection was conducted for all patients except one who was not diagnosed until after the surgery. No recurrence occurred during the follow-up (range: 6 months to 17 years) and all patients have survived to date. The preoperative diagnosis rate of Hashimoto's disease with thyroid cancer (in particular thyroid microcarcinomas) is low. Preoperative palpation, color Doppler ultrasound, fine needle aspiration, and the frozen section examination are helpful to improve the diagnosis rate of Hashimoto's disease with thyroid microcarcinoma. Surgery procedure is the most effective approach.

Prognostic analyses of intramedullary high grade astrocytomas

To explore the prognostic factors of intramedullary high grade astrocytomas. Retrospective analyses were conducted for 21 surgical patients with high grade astrocytoma in spinal cord during 2008 to 2012 at our hospital. Their preoperative and postoperative profiles were recorded and evaluated by modified McCormick classification scheme. Their median age was 32.5 years. There were anaplastic astrocytoma (n = 14) and glioblastoma (n = 7). The prognoses of high grade astrocytomas were correlated with pathology grade and MIB-1 index. No statistic significance existed in age, gender, McCormick score, extent of resection, radiotherapy or chemotherapy. Intramedullary high grade astrocytoma has a low incidence, but its outcome is poor. Once definitely diagnosed, operation is recommended as early as possible. Frozen pathology should be performed to determine the extent of resection. After operation, chemotherapy and radiotherapy are also suggested.

A clinical analysis of multilocular cystic renal cell carcinoma and its correlation with mutation of the von Hippel-Lindau gene

Objective To discuss the diagnosis and surgical management of multilocular cystic renal cell carcinoma (MCRCC) and to evaluate the gene function of the mutation of von Hippel-Lindau (VHL) gene in MCRCC. Methods Seventeen MCRCC cases (11 men and 6 women) out of 512 cases of renal cell carcinoma from 2000 to 2010 were retrospectively analyzed. The mean age of the 17 patients was 46 years (37-61 years). Ultrasonography and CT were available in all 17 cases, and 1 case was misdiagnosed as parapelvic renal cyst. The mutation of VHL gene was detected by PCR in the specimens of can-cerous tissue and adjacent normal tissue from 11 cases of MCRCC. Results Three of 17 cases underwent nephron sparing surgery, the others underwent radical nephrectomy. One case underwent unroofing of parapelvic renal cyst, but the rapid frozen pathology of the cyst wall showed renal cell carcinoma of clear type. As a result, radical nephrectomy was eventually performed. All 17 cases were confirmed as MCRCC by eva-luating pathological characteristics, such as the cyst wall lined by single or several layers of clear tumor cells and the nuclei which were small and anachromasis. Clinical stages of all cases were T1N0M0, in which there were 14 cases with pathological T1G1 and 3 cases with pathological T1G2. All patients underwent a follow-up of 9 to 36 months (mean, 12 months) without recurrence or metastasis. Mutation of VHL gene was detected in 7 of 11 cases (64%), but all adjacent normal tissues were negative. Conclusions As a rare subtype of renal cell carcinoma, MCRCC is difficult to diagnose. CT is an essential measure in diagnosis of MCRCC preoperatively. Because of the good prognosis of reported cases, nephron sparing surgery for the treatment of MCRCC is recommended. VHL gene mutations may play an important role in the carcinogenesis of MCRCC. Key words: Kidney diseases, cystic; Carcinoma, renal cell; Hippel-Lindau disease; Genes; Mutation