Intraoperative consultation
Revision as of 15:07, 3 February 2013 by Michael (talk | contribs) (→Specific specimens - checklists: +parathyroid)
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]
- Determine diagnosis & appropriate extent of operation ~ 50%.
- 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.[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.
- Vulvar melanoma.
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:
- Bronchus - margins.
- Lymph nodes - staging.
Neurologic
- Brain tumour - diagnosis.
- Spinal tumour - diagnosis.
Thyroid gland
- Thyroid nodule - diagnosis.
Prosthetic joint
- 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.
- 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 |
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:[6]
- 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
Main article: Parathyroid gland
Possibilities:
- Parathyroid gland: †
- Benign parathyroid gland.
- Parathyroid adenoma.
- Parathyroid hyperplasia.
- Parathyroid carcinoma.
- Thyroid gland.
- Lymph node.
- Fibroadipose tissue.
Note:
- † It is not possible to determine which one without history or all parathyroid glands.
Checklist
- Weight.
- Dimensions.
- Appearance.
Sign out
QUERY PARATHYROID GLAND: - PARATHYROID GLAND.
See also
References
- ↑ 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.
- ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 5. ISBN 978-0781767798.
- ↑ URL: http://www.adasp.org/papers/position/QualityAssurance.htm. Accessed on: 2 March 2012.
- ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 33. ISBN 978-0781767798.
- ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 34. ISBN 978-0781767798.
- ↑ Taxy, J.; Husain, A; Montag, A. (2009). Biopsy Interpretation: The Frozen Section (1st ed.). Lippincott Williams & Wilkins. pp. 43. ISBN 978-0781767798.