Difference between revisions of "Intraoperative consultation"

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'''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.
[[Image:Tissue for frozen section in cryostat.JPG|thumb|right|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:<ref name=pmid8554440>{{Cite journal  | last1 = Zarbo | first1 = RJ. | last2 = Schmidt | first2 = WA. | last3 = Bachner | first3 = P. | last4 = Howanitz | first4 = PJ. | last5 = Meier | first5 = FA. | last6 = Schifman | first6 = RB. | last7 = Boone | first7 = DJ. | last8 = Herron | first8 = RM. | title = Indications and immediate patient outcomes of pathology intraoperative consultations. College of American Pathologists/Centers for Disease Control and Prevention Outcomes Working Group Study. | journal = Arch Pathol Lab Med | volume = 120 | issue = 1 | pages = 19-25 | month = Jan | year = 1996 | doi =  | PMID = 8554440 }}
</ref>
#Determine diagnosis & appropriate extent of operation ~ 50%.
#[[Margins|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.<ref>{{Ref BITFS|5}}</ref>
 
===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|Quality}}
 
Categories by the ''Association of Directors of
Anatomic and Surgical Pathology'' (ADASP):<ref name=adasp>URL: [http://www.adasp.org/papers/position/QualityAssurance.htm http://www.adasp.org/papers/position/QualityAssurance.htm]. Accessed on: 2 March 2012.</ref>
*Agreement
*Deferral - appropriate.
*Deferral – inappropriate
**Recommendation <=10% threshold.
*Disagreement – Minor.
*Disagreement – Major.
**Recommendation <=3% threshold.


==Common specimens==
==Common specimens==
Gynecologic:
===Table of common FS specimens===
*Pelvic mass - diagnosis.
{| class="wikitable sortable"
*Ovarian mass - diagnosis.
! Specimen
*Uterine mass - diagnosis.
! Indication
*Sentinel lymph node - staging.
! Subspecialty
|-
| Pelvic mass
| diagnosis
| [[gynecologic pathology]]
|-
| Ovarian mass
| diagnosis
| [[gynecologic pathology]]
|-
| Uterine mass
| diagnosis
| [[gynecologic pathology]]
|-
| [[Sentinel lymph node]]
| staging in [[vulva]]r 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]]
| [[joints|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.
**[[Vulva]]r melanoma.
**[[Vulva]]r melanoma.


Head and neck:
====Head and neck====
*Squamous cell carcinoma - margins.
*Squamous cell carcinoma - margins.
*Thyroid nodule - diagnosis.
*Parathyroid - confirm it is parathyroid.


Gastrointestinal tract:
====Gastrointestinal tract====
*Whipple procedure - margins.
*Whipple procedure - margins.
*Liver resection - margins.
*Liver resection - margins.
*Lower anterior resection - distal margin.
*Lower anterior resection - distal margin.


Genitourinary tract:
====Genitourinary tract====
*Cystectomy - ureteral margins.
*Cystoprostatectomy/cystectomy - ureteral margins.


Pulmonary:
====Pulmonary====
*Pneumonectomy:
*Pneumonectomy:
**Bronchus - margins.
**Bronchus - margins.
**Lymph nodes - staging.
**[[Lymph nodes]] - staging.


Neurologic:
====Neurologic====
*Brain tumour - diagnosis.
*[[Brain tumour]] - diagnosis.
*Spinal tumour - diagnosis.
*Spinal tumour - diagnosis.


Thyroid gland:
====Prosthetic joint====
*Thyroid nodule - diagnosis.
*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''<ref name=pmid22032564>{{Cite journal  | last1 = Nakhleh | first1 = RE. | title = Quality in surgical pathology communication and reporting. | journal = Arch Pathol Lab Med | volume = 135 | issue = 11 | pages = 1394-7 | month = Nov | year = 2011 | doi = 10.5858/arpa.2011-0192-RA | PMID = 22032564 | URL = http://www.archivesofpathology.org/doi/full/10.5858/arpa.2011-0192-RA  }}</ref>).
# 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<ref>{{Ref BITFS|33}}</ref>).
**Mucinous: high viscosity (jello-like consistency).
 
====DDx====
{| class="wikitable sortable"
! 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;<ref>{{Ref BITFS|34}}</ref>
''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:<ref>{{Ref BITFS|43}}</ref>
*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|Parathyroid gland}}
Possibilities:
*Parathyroid gland:
**Benign parathyroid gland.
**[[Parathyroid adenoma]]. †
**[[Parathyroid hyperplasia]]. †
**[[Parathyroid carcinoma]].
*Thyroid gland.
**Thyroid usually follicular - though parathyroid occasionally is pseudofollicular.
**Thyroid often has birefringent (calcium oxalate) crystals (60 of 80 cases) whereas parathyroid less often does (2 or 20 cases).<ref name=pmid24618617>{{cite journal |authors=Wong KS, Lewis JS, Gottipati S, Chernock RD |title=Utility of birefringent crystal identification by polarized light microscopy in distinguishing thyroid from parathyroid tissue on intraoperative frozen sections |journal=Am J Surg Pathol |volume=38 |issue=9 |pages=1212–9 |date=September 2014 |pmid=24618617 |doi=10.1097/PAS.0000000000000204 |url=}}</ref>
*[[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.<ref name=pmid16360503>{{Cite journal  | last1 = Dewan | first1 = AK. | last2 = Kapadia | first2 = SB. | last3 = Hollenbeak | first3 = CS. | last4 = Stack | first4 = BC. | title = Is routine frozen section necessary for parathyroid surgery? | journal = Otolaryngol Head Neck Surg | volume = 133 | issue = 6 | pages = 857-62 | month = Dec | year = 2005 | doi = 10.1016/j.otohns.2005.05.001 | PMID = 16360503 }}</ref>
 
====Checklist====
*Weight.
*Dimensions.
*Appearance.
 
====Sign out====
<pre>
Query Parathyroid Gland:
- Hypercellular parathyroid tissue.
</pre>
 
<pre>
QUERY PARATHYROID GLAND:
- PARATHYROID GLAND.
</pre>
 
===Whipple specimen===
====Sign out====
<pre>
BILE DUCT MARGIN:
- NEGATIVE FOR MALIGNANCY.
</pre>
 
===Skin specimens===
{{Main|Oriented skin ellipse grossing}}
{{Main|Unoriented skin ellipse grossing}}
{{Main|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 margin|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|grossing separately received oriented margins for a skin ellipse]]''.


==See also==
==See also==
*[[Basics]].
*[[Basics]].
==References==
{{Reflist|2}}


[[Category:Basics]]
[[Category:Basics]]

Latest revision as of 16:15, 15 December 2023

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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