Difference between revisions of "Intraoperative consultation"

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====DDx====
====DDx====
*Unilocular cysts:
{| class="wikitable sortable"
**Follicular ''or'' epithelial.
! Feature
***Very rare [[granulosa cell tumour]] - not typically diagnosed at FS.
! Dx/DDx
**No excrescences or solid areas = "simple cyst".
! Notes
*Sebaceous material or hair = teratoma.
|-
**If ''Rokitansky nodule'' present: submit section.
| Unilocular cysts
***Neuroepithelium = fleshy appearance on gross.<ref>{{Ref BITFS|34}}</ref>
| follicular cyst, epithelial cyst, very rarely [[granulosa cell tumour]] (not typically diagnosed at FS)
***''Immature teratoma'' 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
|}


==See also==
==See also==

Revision as of 02:15, 18 January 2013

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 thyroid pathology
Prosthetic joint query prosthetic joint infection joint 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

  • 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.
  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[4]).
    • 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;[5]

immature teratoma not typically diagnosed at FS

Chocolate cyst endometriosis solid elements (fibrosis vs. clear cell & endometrioid carcinoma

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. ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 33. ISBN 978-0781767798.
  5. ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 34. ISBN 978-0781767798.
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