Intraoperative Frozen Section Consultation Research Articles

Implementation of a required 3rd-year medical student surgical pathology clinical experience

Few medical schools have required experience ​in surgical pathology during the clinical years. After introducing a pilot and preliminary surgical pathology clinical experience into the curriculum, we initiated a required 3rd-year medical student surgical pathology clinical experience that consisted of a one hour introductory lecture; one hour gross room, histology, and immunohistochemistry laboratory introduction; and one hour of one-on-one case sign-out preceptorship with a subspecialty surgical pathologist within the surgery and obstetrics/gynecology block. Concepts that were covered included specimen processing, intraoperative frozen section consultation, completing specimen requisitions, interpreting synoptic reports, and pTNM staging. Students evaluated the surgical pathologist from 1 to 5 (1 “poor/unhelpful,” 2 “marginal,” 3 “neutral,” 4 “good,” 5 “excellent/useful”). Ten multiple-choice questions (included as part of a perioperative services exam) and attendance were incorporated into students’ perioperative services rotation grade. From 2014 to 2018, 757 students participated in the required 3rd-year surgical pathology clinical experience. Thirty academic subspecialty pathologists acted as preceptors with an average of nine sessions per preceptor per year. Evaluation data from 316 students from 2015 to 2018 showed a mean preceptor rating of 4.8/5 (range 4.0–5.0). Students scored an average of 81% on the surgical pathology portion of the exam (range 21–99% for each question). We successfully implemented a required medical student surgical pathology clinical experience. At the clerkship’s conclusion, students demonstrated understanding of key concepts and rated their preceptorship experience highly.

Molecular imaging can identify the location to perform a frozen biopsy during intraoperative frozen section consultation.

BackgroundIntraoperative frozen section (FS) consultation is an important tool in surgical oncology that suffers from sampling error because the pathologist does not always know where to perform a biopsy of the surgical specimen. Intraoperative molecular imaging is a technology used in the OR to visualize lesions during surgery. We hypothesized that molecular imaging can address this pathology challenge in FS by visualizing the cancer cells in the specimen in the pathology suite. Here, we report the development and validation of a molecular-imaging capable cryostat called Smart-Cut.MethodsA molecular imaging capable cryostat prototype was developed and tested using a murine model. Tumors grown in mice were targeted with a NIR contrast agent, indocyanine green (ICG), via tail vein injection. Tumors and adjacent normal tissue samples were frozen sectioned with Smart-Cut. Fluorescent sections and non-fluorescent sections were prepared for H&E and fluorescent microscopy. Fluorescent signal was quantified by tumor-to-background ratio (TBR). NIR fluorescence was tested in one patient enrolled in a clinical trial.ResultsThe Smart-Cut prototype has a small footprint and fits well in the pathology suite. Fluorescence imaging with Smart-Cut identified cancerous tissue in the specimen in all 12 mice. No false positives or false negatives were seen, as confirmed by H&E. The mean TBR in Smart-Cut positive tissue sections was 6.8 (SD±3.8). In a clinical application in the pathology suite, NIR imaging identified two lesions in a pulmonary resection specimen, where traditional grossing only identified one.ConclusionMolecular imaging can be integrated into the pathology suite via the Smart-Cut device, and can detect cancer in frozen tissue sections using molecular imaging in a murine model.

Intraoperative frozen section consultation- an audit in a tertiary care hospital

Introduction: Frozen section (FS) helps the surgeon in the surgical management of the patient by helping in the intraoperative diagnosis of tumors, margins and lymphnode assessment, and organ identification. Audits of the frozen section consultations help in identifying the pitfalls and to carry out appropriate preventive measures for its optimal usage. We report the results of the study of our FS consultations. Materials and Methods: A retrospective study of 518 specimens from 132 consecutive cases of FS consultations was carried out. The FS report and formalin fixed tissue reports were compared and analyzed. The results were categorized into concordant, discordant and deferred consultations. Causes of discrepancy were analysed and diagnostic accuracy, diagnostic error rates, sensitivity, specificity, indications, tissue type, turnaround time and limitations were noted. Results: An average of 3.92 specimens per patient was received with 80(60.61%) males and 52(39.39%) females. Age ranged from 15 to 80 years. Male and female general surgical departments were the major contributors with 64 (48.48%) and 25 (18.94%) consultations respectively. Oropharyngolaryngeal region (48.84%) was the main site sampled. The main indication was margin status assessment (52.27%). Accuracy rate was 98.65% with an error rate of 1.35% was observed. The discordant cases had misinterpretation error in 5 cases and sampling errors in the remaining 2 cases. Three cases (0.58%) were deferred. Sensitivity (90.91%) and specificity (96.59%) was obtained. Conclusions: The study turned out as a quality check and identified the areas requiring improvement to reduce the error rates. Keywords: Frozen section, Retrospective study, Accuracy, Error, Margin status, Sensitivity.

Multifocal endometriosis

Endometriosis represents a complex entity, characterized by tissue located in ectopic sites, outside uterus, with the highest incidence in ovaries and peritoneum. We report a rare case, with multiple endometriotic foci, in a 34 year old woman. The patient presented with intestinal subocclusion syndrome, associated with pelvic and abdominal pain. The imagistic exploration identified two peritoneal and one left ovarian masses and the clinical exam detected a 48/22 mm Douglas pouch mass. The surgical treatment, by exploratory laparotomy, resulted in segmental resection of the rectosigmoid junction and left adnexectomy. The intraoperative frozen section consultation, followed by paraffin-embedded, routine and immunohistochemical staining, led to a rare diagnosis of multiple foci of endometriosis, involving left adnexa, colorectum, and pericolic lymph nodes, without any atypia or malignancy. The postoperative evolution had been favorable. According to the identification of multiple endometriotic foci in our case, the hypothesis of different etiopathogenic mechanisms involvement may be supported by our findings.

Intraoperative frozen section consultation in gynecologic pathology.

Intraoperative consultation (IOC) in gynecologic pathology is aimed at providing or confirming the diagnosis at the time of surgery and evaluating the extent of disease in order to assist the surgeon in determining the surgical procedure being performed. This chapter discusses the main indications for IOC in gynecologic pathology and describes how to submit and process these specimens in order to obtain optimal material. In addition, diagnostic pitfalls and ancillary testing related to IOC in gynecologic pathology are summarized.

Primary Paraganglioma of Thyroid Gland: A Clinicopathologic and Immunohistochemical Analysis of Three Cases with a Review of the Literature

Thyroid paraganglioma is an extremely rare tumor and frequently mistaken for other thyroid neoplasms. Increased awareness of its potential presentation in thyroid and its characteristic features is essential for avoiding diagnostic and therapeutic pitfalls. We describe here three additional cases of primary thyroid paraganglioma and analyze their clinical findings and pathological characteristics. Patients included two women and one man presenting with asymptomatic thyroid nodules. Radiological examinations were nonspecific and none had been diagnosed correctly before surgery. On intraoperative frozen section consultation they were all misdiagnosed as carcinomas, either primary or metastatic. However, the permanent sections showed features consistent with paraganglioma. Of note, two cases displayed extension into adjacent thyroid tissues, one of which exhibited increased mitotic activity, confluent tumor necrosis and vascular invasion. Immunohistochemically, the neoplastic chief cells expressed chromogranin, synaptophysin, neuron-specific enolase and CD56, whereas the sustentacular cells were highlighted by S100 protein. All three patients were well with normal hormone secretion, without local recurrence or distant metastasis at last follow-up (range 10-47months). We further reviewed the literature to summarize the characteristics of this distinctive entity. Albeit being very rare, paraganglioma should be included in the differential diagnosis of hypervascular thyroidal neoplasms. Accurate diagnosis relies on the histopathogical findings and adjunctive immunohistochemcial studies. To date, all the reported cases have pursued a benign course. Although atypical features seem to have no association with clinical behavior, long time postoperative surveillance with biochemical screening of hormone secretion, cervical ultrasonography and whole-body CT scan is recommended.

Enhancing Value of Pituitary Surgery by Maintaining Quality and Reducing Cost

Introduction: Our center performs approximately 60 endoscopic transnasal transsphenoidal (eTNTS) pituitary operations per year. Traditionally, for every operation we obtained intraoperative frozen section consultation (IFSC), used a dural sealant (DS), and obtained postoperative magnetic resonance imaging (MRI). Our objective was to enhance the value of the operation by optimizing the cost of hospitalization, while maintaining an equal quality of care.

Utilization of frozen sections in the evaluation of chronic epilepsy–related cases

The role of frozen section consultation in the evaluation of chronic epilepsy-associated surgical excisions of brain tissue has not been previously examined. The study retrospectively reviews 335 cases in which a frozen section consultation was obtained in the setting of a resection for chronic epilepsy. In most cases (n = 323), 3 or fewer frozen sections were performed. The most commonly identified pathologies on final diagnosis included tumor or tumorlike lesions (79.1% of cases) and focal cortical dysplasia (20.9% of cases). Frozen section diagnoses discrepant with final diagnoses due to sampling error or misinterpretation were noted in 39 cases and most commonly involved a diagnosis of gliosis or tumor in the setting of a focal cortical dysplasia or diagnosis of gliosis in the setting of a low-grade tumor. In conclusion, frozen section consultation may be particularly useful in the evaluation of neoplasms arising in the setting of chronic epilepsy. Some epilepsy-associated pathology, such as focal cortical dysplasia, may be difficult to diagnose at the time of frozen section and such cases may not be an ideal target for intraoperative frozen section consultation.

Unilateral malignant struma ovarii in a case of bilateral ovarian teratoma with raised CA-125 level: A rare case with treatment dilemmas

Struma ovarii are specialized form of mature ovarian teratoma comprised predominantly of thyroid tissue (>50%). Most of the struma ovarii are benign; rarely can they undergo malignant transformation. Elevated CA-125 levels with benign struma ovarii have been seen in only 5 cases in literature. The association of malignant struma ovarii and high CA-125 levels with pseudo-Meig syndrome has been reported in only 2 cases in English literature. We describe a case of a 46-year-old multigravida who presented with an abdominal mass and raised CA-125 levels. Radiological investigations revealed bilateral cystic adnexal masses with ossified elements on left side suggesting a teratoma. Intraoperative frozen section and final pathology revealed bilateral teratoma with follicular variant of papillary thyroid carcinoma arising in the left ovary. To the best of our knowledge, this is the first case of malignant struma ovarii in combination with bilateral teratoma. The dilemmas related to preoperative diagnoses with elevated CA-125 levels, mimicking an epithelial ovarian neoplasm; intraoperative frozen section consultation; management and follow-up issues in this rare malignancy are discussed.

Invasive lobular carcinoma of the breast presenting as retroperitoneal fibrosis: a case report

IntroductionInvasive lobular carcinoma of the breast represents approximately 6.3% of mammary malignancies. Distant metastasis of invasive lobular carcinoma to the peritoneum or retroperitoneum has been reported fairly frequently.Case presentationWe report the case of a 59-year-old Caucasian-Canadian woman with invasive lobular carcinoma of the breast presenting with retroperitoneal fibrosis and bilateral ureteral obstruction. Intra-operative pathology consultation did not reveal malignancy. The diagnosis, however, was confirmed on permanent sections by histological appearance in addition to immunohistochemistry. To the best of our knowledge, this is the first reported case of invasive lobular carcinoma of the breast presenting with retroperitoneal fibrosis.ConclusionIn a case of unexplained ureteric obstruction and retroperitoneal fibrosis, more comprehensive physical examination and additional ancillary studies may be warranted to rule out malignancy as an underlying etiology. This case also emphasizes that intra-operative frozen section consultation cannot always be fully relied upon to exclude a malignancy as the etiology of retroperitoneal fibrosis. Moreover, in permanent histopathology sections, immunohistochemistry testing can be of value to rule out metastatic disease where the morphology is not salient. There is a need for a thorough physical examination of patients with retroperitoneal fibrosis, including the breast and gynecological organs.

Clear Cell Follicular Adenoma of the Thyroid – A Challenge in Intra-operative Diagnostics

Pure clear cell lesions of the thyroid gland are rare and prone to pose severe diagnostic challenges. We report the case of a 61-year-old man with a clear cell adenoma of the thyroid. The patient presented with a hypoechoic thyroid nodule. Fine needle aspiration cytology rendered the primary diagnosis of a follicular neoplasia, and right thyroid lobectomy was performed. By intra-operative frozen section, the diagnosis given was clear cell lesion of unknown malignant potential. Based on the light microscopic findings and the immunohistochemical profile, the lesion was diagnosed as clear cell follicular adenoma of the thyroid. A follicular thyroid lesion presenting with clear cell changes in fine needle aspiration cytology or intra-operative frozen section consultation constitutes a diagnostic challenge to every surgical pathologist. As immunohistochemistry of cytologic specimens is hampered by several methodological problems, any thyroid lesion with clear cell features warrants further histologic assessment to render the correct diagnosis.

Vulvar basal cell carcinoma in China: a 13-year review

We conducted a 12-year retrospective review of vulvar basal cell carcinoma (BCC) in a Chinese population. Medical records and histopathologic reports were examined from 5 major Hospitals in Hong Kong to list all patients diagnosed with vulvar BCC. Clinical data and histologic materials were reviewed. Sixteen vulvar BCCs were diagnosed. Most of them were pigmented. They were removed by simple excision or wide local excision. All the carcinomas were identified in the reticular dermis. The predominant histologic pattern was nodular, which may be mistaken as adenoid cystic carcinoma. The high proportion of pigmented vulvar BCCs suggested that biopsy should be performed for any pigmented lesion in a Chinese patient. The BCCs are superficial and tissue-preserving treatment approach is recommended. The tumor depth estimation is difficult and intraoperative frozen section consultation may be helpful. Formal histopathologic assessment should be used to reach an objective diagnosis.

Q-tracks: a College of American Pathologists program of continuous laboratory monitoring and longitudinal tracking.

Continuous monitoring of key laboratory indicators of quality by hundreds of laboratories in a standardized measurement program affords an opportunity to document the influence of longitudinal tracking on performance improvement by participants focused on that outcome. To describe the results of the first 2 years of participation in a unique continuous performance assessment program for pathology and laboratory medicine. Participants in any of 6 modules in the 1999 and 2000 College of American Pathologists (CAP) Q-Tracks program collected data according to defined methods and sampling intervals on standardized input forms. Data were submitted quarterly to CAP for statistical analysis. Interinstitutional comparison reports returned in 6 weeks provided each laboratory with its performance profile of key indicators and its percentile ranking compared with all participants in that quarter. This also included longitudinal comparisons of performance during previous cumulative quarters. Control charts graphically displayed data with flags identifying performance points that were out of statistical control. Hospital-based laboratories in the United States (98%), Canada, and Australia. Voluntary subscriber laboratories in the CAP Q-Tracks performance measurement program: roughly 70% from hospitals of 300 occupied beds or fewer, 65% from private, nonprofit institutions, slightly more than half located in cities, one third from teaching hospitals, and 20% with pathology residency training programs. Each module measured several major and additional minor quality indicators and unbenchmarked individualized data for internal use. Participants in 4 of 6 Q-Tracks continuous monitors demonstrated statistically significant performance improvement trends in 1999 and 2000, which were most marked for laboratories that continued participation throughout both years. These monitors were wristband patient identification, laboratory specimen acceptability, blood product wastage, and intraoperative frozen section consultation. Key continuous indicators chosen on the basis of a decade's experience in the CAP Q-Probes quality improvement program are useful measurement and benchmarking tools for laboratories to improve performance. In general, measures in which there is a broad range of demonstrable performance initially are most optimal for subsequent improvement using continuous monitoring. These studies have shown that quality is not static, but rather is a moving benchmark of performance as seen in the redefinition of benchmarks over time by participants in the first 2 years of the CAP Q-Tracks program.

Use of aspiration cytology and frozen section examination for management of benign and malignant thyroid nodules

Between January 1980 and December 1988, 161 patients underwent thyroidectomy with intraoperative frozen section consultation after fine-needle aspiration (FNA) of a thyroid nodule. The FNA were insufficient in 15 instances (9%) and in error in 39 (24%). In 15 cases, the incorrect aspiration diagnosis could have led to excessive surgery and in ten cases to delayed therapy if it had been the only guide for therapy. The diagnosis was deferred to permanent section analysis in 30 (19%) frozen sections. Twenty-two errors (14% of cases) were made in the interpretation of frozen section material, and in an additional 15 patients (9%), the diagnosis suggested (but deferred at frozen section) was in error. In one patient, this error could have led to more extensive surgery than necessary; in 21 patients, the frozen section error could have led to undertreatment. When frozen section results were combined with those of FNA, no therapeutically important false-positive diagnoses were made. In five patients, the combination of both FNA and frozen section results would not have identified a carcinoma which, in three cases, was a small occult papillary carcinoma not found in the index nodule.