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Dedication

This book is dedicated to all the pathologists whose hearts race when alerted by the frozen section pager, to the support staff in the intraoperative consultation room who are always there to assist them, to the surgeons who request essential information to help guide their operations, and most of all, to the patients who have entrusted their care into our hands.

Matthew R. Lindberg, MD

Assistant Professor Department of Pathology

University of Arkansas for Medical Sciences

Little Rock, Arkansas

Emily F. Mason, MD, PhD

Assistant Professor of Pathology

Vanderbilt University Nashville, Tennessee

Vania Nosé, MD, PhD

Associate Chief of Pathology

Director of Anatomic and Molecular Pathology

Massachusetts General Hospital

Professor of Pathology

Harvard Medical School

Boston, Massachusetts

Charles Matthew Quick, MD

Associate Professor of Pathology

Director of Gynecologic Pathology

Department of Pathology

University of Arkansas for Medical Sciences

Little Rock, Arkansas

Matija Snuderl, MD

Assistant Professor of Pathology

Director of Molecular Pathology and Diagnostics

NYU Langone Medical Center

New York, New York

Amitabh Srivastava, MD

Associate Professor of Pathology

Harvard Medical School

Associate Director, Surgical Pathology

Director, Surgical Pathology Fellowship Program

Brigham and Women’s Hospital Boston, Massachusetts

Karen S. Thompson, MD

Professor and Interim Chair, Department of Pathology

John A. Burns School of Medicine

University of Hawaii

Pan Pacific Pathologists, Clinical Laboratories of Hawaii

Kapiolani Medical Center for Women and Children

Honolulu, Hawaii

Additional Contributing Authors

Stefan Kraft, MD

Rolf Pfannl, MD

Acknowledgments

Lead Editor

Megg Morin, BA

Text Editors

Arthur G. Gelsinger, MA

Rebecca L. Bluth, BA

Nina I. Bennett, BA

Terry W. Ferrell, MS

Lisa A. Gervais, BS

Matt W. Hoecherl, BS

Image Editors

Jeffrey J. Marmorstone, BS

Lisa A. M. Steadman, BS

Illustrations

Richard Coombs, MS

Lane R. Bennion, MS

Laura C. Wissler, MA

Art Direction and Design

Tom M. Olson, BA

Laura C. Wissler, MA

Production Coordinators

Angela M. G. Terry, BA

Emily C. Fassett, BA

SECTION 1: General

SECTION 2: Methods

SECTION 3: Contents

IntraoperativeConsultation:Introduction

THEARTOFINTRAOPERATIVE CONSULTATION

MoreThanPathologyatHighSpeed

•Intraoperativeconsultation(IOC)hassignificantdifferences comparedtogeneralpathologypractice

○Majorpurposeistoansweraspecificquestionrequired fordirectingsurgery

–Diagnosishasimmediateimpactoncareofpatient

○Definitivediagnosisgenerallynotnecessaryoroptimal

–Informationshouldbelimitedtothatessentialfor immediatemanagementofpatient

–Majorityofspecialstudiesnotavailable;diagnosis basedalmostexclusivelyonH&Eslides

–Onlylimitedsamplingoflargespecimenspossible withintimelimits

○Judiciousinterpretationoffindingsoftennecessary givenlimitationoffrozensections

–Conservativeapproach,butnottooconservative,is appropriate

–Degreesofuncertaintywhenadefinitivediagnosisis notpossiblemayneedtobesharedwithsurgeon

○Time-limitedconsultation

–Ideally,ananswerisavailabletosurgeonwithin20 minutes

–Takesprecedenceoverallotheractivities

–Inmostinstitutions,apathologistisavailableoncall forconsultationatalltimes

○Directinteractionbetweenpathologistandsurgeonis preferred

–Preciseoralandwrittencommunicationisessential

○Oftenoccursatasitedistantfrompathology department

–Pathologiststypicallypreferusingtheirown microscopeintheirownworkspace

○Doesnotoccuratpredeterminedtime

–Mayberequestedattimesoutsidenormalworking hours(e.g.,nightsandweekends)

○Referencematerialmaybelimitedordifficulttoaccess (e.g.,booksandjournals)

(Left)Closecooperationand communicationbetween surgicalandpathologyteams (preferablyinperson)is imperativetomakingsurethe patientreceivestheoptimal treatmentintheoperating room.[CourtesyL.Cheney,PA (ASCP)cm,andE.Rhei,MD.]

(Right)Intraoperative consultationhasfeaturesthat setitapartfromgeneral pathologypracticeinmany waysandrequiresa specializedskillsetand diagnosticacumenina challengingandtime-limited professionalsetting.(Courtesy W.Welch,MD.)

○Consultationwithcolleaguesoftennotpossible

○Notsubspecialized;pathologistsmayseespecimens outsidetheirareasofexpertise

•Pathologistplaysimportantroleinadvocatingforpatient duringIOC

○Shouldonlycomplywithrequestsforfrozensection whentheyareinbestinterestofpatient

○Shouldrequestadditionalbiopsieswhenreceived materialisnotsufficientfordiagnosis

○Mustensurethattissueisused1stfordiagnosisand clinicalcareandonly2ndforinvestigationalstudiesand otheruses

•Pearlsofknowledgearesuggestionsandadvice

○Pearlsstartasgrainofsandbutgainvalueovertime

○Knowledgeisgainedafterlongyearsofexperiencewith IOC,manyclosecalls,andafewerrors

○Learningfromerrorsisanexcellentmethodtoimprove practice(especiallywhenerrorsarenotyours)

GoalsofIntraoperativeConsultation

•Thereare3principalreasonsforimmediatemicroscopic evaluationofspecimens

○ Diagnosistoguideintra-orperioperativepatient management

–Identificationorconfirmationofpathologicprocess

–Evaluationofmarginsforknownmalignancy

○ Confirmsufficientlesionaltissueispresentfor diagnosisonpermanentsections&/orafterspecial studies

–Definitivediagnosisisnotnecessaryintraoperative

–Pathologistconfirmstosurgeonthereisnoneedto removeadditionaltissue,resultinginpossible additionalmorbidity

○ Optimallyprocesstissueforancillarystudiestobe usedfordiagnosis,treatment,orresearch

–Lymphomas

–Sarcomas

–Pediatrictumors

–Othertumorsrequiringspecialhandling

IntraoperativeConsultation:Gross Findings

IntraoperativeConsultation:Microscopic Findings

IntraoperativeConsultation:Introduction

MostCommonDiagnosticQuestions

• Diagnosisofprimarylesion(~20%)

○Inmanycases,preoperativediagnosisispossibleusing needleorendoscopicbiopsies

–Insomecases,priorattempttodiagnosemayhave beenunsuccessfulorcontraindicatedduetolocation ortypeoflesion

○Definitivediagnosisneedonlybeprovidedwhen relevanttoimmediatepatientmanagement

–Oftenbenignvs.malignantissufficientfor intraoperativemanagement

–Provisionaldiagnosiscanaidinallocationoftissuefor ancillarystudies

–Inmanycases(e.g.,lymphomas,smallroundbluecell tumors,andsofttissuetumors),ancillarystudiesare oftencritical;definitivediagnosisattimeofIOCis unnecessary

• Evaluationofmarginsforknownmalignanttumor(~ 40%)

○Additionaltissuemaybetakentoachievenegative marginsinasingleprocedure

○Accuracyisgenerallyveryhigh

• Identificationoflymphnodemetastasis(~20%)

○Resectionwithcurativeintentmaybecanceledif metastaticdiseaseisidentified

–Additionalnodesmaynotneedtobesampled

–Patientsmaybetreatedwithsystemictherapypriorto definitiveresection

○Ifapositivesentinelnodeisidentified,additionalnodes maybeexcised

• Adequacyoftissueforfuturediagnosis(~5%)

○Presurgicaltreatmentisbecomingmorewidelyusedto reducetumorburdenandasameasureoftumor response

○Tumorsmustbediagnosedwithcertaintypriorto treatment

–Freshtissuemayalsobedesirableforancillarystudies toidentifycellularconstituentsvulnerabletotargeted therapy

–Patientsmayalsoconsenttohavetissuetakenfor tumorbanks

○Pathologistmustrequestadditionaltissuewhen appropriate

• Evaluationoforganpriortotransplant(<5%)

○Scarcityoforganshasresultedindonorpoolbeing expandedtoincludedonorswithpossiblymarginally functionalorgans

○Intraoperativeassessmentisimportanttoavoid transplantationoforganswithhighlikelihoodoffailure

ChangesinIntraoperativeConsultationOverTime

•NeedforIOCchangesastreatmentofpatientschanges

• Consultationsbecomingmorecommon

○Evaluationoflunglesionsdetectedbyscreening

–UnitedStatesPreventativeServicesTaskForceissued recommendationsforscreeningforlungcancerusing annuallow-dosecomputedtomographyfor individualsbetweentheagesof55-80with30-year historyofsmokingandwhocurrentlysmokeorhave quitsmokingwithinlast15years

–Lesionsdetectedbyscreeningaretypicallysmallorof lowdensity(groundglass)

–Lesionscanbedifficultorimpossibleforsurgeonto palpate

□Speciallocalizationtechniquesmayberequired

–Morelimitedsurgerymaybeconsideredfor adenocarcinomainsituorminimallyinvasive adenocarcinoma

○Evaluationofmarginsofpartialnephrectomies

–Smallrenaltumorsaredetectedbyimaging

–Increasedeffortisbeingmadetopreserverenal functiontoavoidneedfordialysis

○Radioactiveseedretrieval

–Theuseofradioactiveseedsratherthanwirestomark breastlesionshasmanyadvantagesforpatientsand surgeons

–RetrievaloftheseedintheIOCroommaybe preferredtoensureallseedsareidentified, documented,andstoreduntiltheycanbedisposedof safely

○Nipplemarginofmastectomies

–Nipple-andskin-sparingmastectomiesoffer cosmeticallysuperiorprocedureforcarefullyselected women

–Thebaseofthenipplemaybeexamined intraoperativelywithremovalofnipplewhen carcinomaisdetected

○Evaluationoforganspriortotransplant

○Evaluationofsmallbiopsiesforadequacy

• Consultationscurrentlyrarelyperformed

○Identificationofparathyroidadenomas

–Intraoperativemeasurementofparathyroidhormone levelisausefulfunctionalassaythatisusedtoguide surgery

○Sentinelnodeevaluationforbreastcarcinoma

–Studieshaveshowngoodoutcomesforcarefully selectedwomenwithpositivesentinelnodeswithout axillarydissection

–Theneedtodetermineifmetastaticcarcinomaisin sentinelnodeintraoperativelyhasdiminished

○Primarydiagnosisofbreastlesions

–Coreneedlebiopsiesarehighlyaccurateandallow decisionstobemadeconcerningchoiceofsurgery andsystemictherapy(neoadjuvantoradjuvant)

–Definitivesurgerycanbeplannedbasedonthecore needlebiopsydiagnosis

Limitations

•Frozensectionsarenotequivalenttoevaluationof specimensonpermanentsections

○Diagnosesonfrozensectionshouldbelimitedto informationneededforintraoperativemanagementof patient

• Sampling

○Tissuesectionsmustbesmalltofreezewellandquickly

○Amountoftissueexaminedislessthanthatexaminedby permanentsections

○ Pearlofknowledge:Thepathologistevaluating microscopicslidesshouldalwaysperform,orbeaware of,thegrossfindings

–Ifmacroscopicandmicroscopicfindingsarenot compatible,pathologistshouldsuspecterror

IntraoperativeConsultation:Introduction

–Tumorsforwhichimagingappearanceiscriticalfor finaldiagnosis(centralnervoussystemtumors,bone tumors)

○ Pearlofknowledge:Reviewingclinicalhistoriespriorto IOCleadstofasterandmoreconfidentdiagnosesand considerablylessanxiety

–Somepeoplebelievethatpathologistsshouldbeable todivineallclinicalinformationfromsurgical specimensastheharuspicesinancientRomewere abletodivineinformationfromexamining organs—thisisnottrue

•IOCrequiringtheallocationoftissueforpurposesbeyond diagnosismustbeidentified

○Tissuerequiredforpatienttreatmentshouldbe distinguishedfromtissuerequestedforresearch

–Patientsmayrequiretissuesamplingtobeeligiblefor clinicaltrials

○Specialproceduresmayberequired

–Steriletissueisnecessaryforcellcultures(e.g.,vaccine studies)

–Warmischemiatime(inoperatingroom)andcold ischemiatime(untiltissueisfrozenorplacedin fixativeshouldbeminimized)

○ Patientcaremustalwaystakeprecedenceoveruseof tissueforresearchthatdoesnotdirectlyimpactpatient

•ObtaininginformationpriortoIOCispreferable,when possible

○DoesnotextendthetimeoftheIOCwhilepatientis underanesthesia

○Allowstimetoreviewpriorpathologyorimagingstudies whenavailable

•Well-designedelectronicmedicalrecordscanfacilitate obtainingkeyinformationpriortotheoperation

ImportantInformationforPathologicInterpretation

•Age:Likelihoodofdiagnosiscanbehighlydependenton age

•Gender:Sometumorshavegender-specificfrequencies

•Priorhistoryofmalignancy

○Metastaticdiseasemustalwaysbeconsidered

○Typeofmalignancy,stage,andpriortreatmentareall importantfactors

○Treatment-relatedchangescanbemistakenfor malignancy

○Tumorswithtreatmenteffectmaybedifficultto recognize

•Priorhistoryofsurgery

○Surgicalchangescanbemistakenformalignancy

•Druguseortherapy

○Drugusecancausechanges(e.g.,increasedmitoses)that canbemistakenformalignancy

•Currentpregnancyorlactation

○Benignbreastlesionscanhaveincreasedmitoticrate &/ornecrosis

–Thesechangescanmimicmalignancy

•Knownorsuspectedinfection

○Somediseasesmayrequiremodificationstoprotect pathologypersonnel

–Specialrespiratorymasksarerequiredtoprotectfrom Mycobacteriumtuberculosis

–SpecimensfrompatientswithsuspectedCreutzfeldtJakobdiseaseshouldnotbeexamined

○Specimensshouldbekeptsterileinordertoobtain cultures

•Imagingfindings

○Insomesettings,appearanceonimagingiscritical

–Essentialtodevelopdifferentialdiagnosis

–Particularlyimportantforbrainlesions,bonetumors, andlunglesions

–Maybenecessarytolocatelesioninlargeresections

InformationProvidedatTimeofIntraoperative

Consultation

• Requisitionform

○Patientidentification,surgeonname,operatingroom number(includingphonenumber)areallessential information

–Knownorsuspectedinfectiousdiseasesshouldbe specified

○Typeofspecimensubmitted

–Location

–Biopsyorcompleteexcision

–Orientation

○Purposeofconsultation

–Inmanycases,willbeclearfromtypeofspecimen submittedandoperativeprocedure

–Ifpurposeisnotclear,pathologistshoulddiscusswith surgeon

– Pearlofknowledge:Ifthereasonforexamining specimenisnotimmediatelyclear,itisanunusualcase andbestcourseofactionistocontactsurgeon

• InformationobtainedduringIOC

○Ifinformationisobtainedfromsurgeonthatishelpful forinterpretationoffrozensection,thiswillalsobe helpfulforfinaldiagnosis

○Informationshouldberecordedonrequisitionformand availabletopathologistreviewingcaseforfinalsignout

• Informationobtainedinoperatingroom

○Insomeinstitutions,itmaybepossibleforthe pathologisttodirectlyobserveoperativefieldandto discussthecasefacetofacewiththesurgeon

REPORTINGRESULTS

WrittenReport

•Diagnosisiswrittenandsignedbyattendingpathologist

○Mostlaboratorieshaveaspecificformforthispurpose

○Formshouldbelabeledwithpatientname,medical recordnumber,andsurgicalpathologynumber

○Specificspecimenandsubdesignationforfrozensection areincluded

•Thediagnosisshoulddirectlyaddressthequestionposed bythesurgeontosuccessfullycompletetheoperation

○ Pearlofknowledge:Diagnosesshouldbebriefand includeonlytheinformationnecessary(e.g.,"notumor present"or"metastaticcancerpresent")

–Longandwordyreportsaredifficulttocommunicate orallyandmorelikelytobemisunderstood

○Avoidusingabbreviations

–Anabbreviationsavestimefor1personand aggravateseveryoneelse

IntraoperativeConsultation:Introduction

HistoryofIntraoperativeConsultations

Era ClinicalSetting Surgery

Pre-1800s Cancerlesscommonaspatientsoften dieduetootherdiseasesatearlyages

1800s Patientscometomedicalattentionlate indiseasewhencancersarelocally advanced

1891

Firstrecordedintraoperative consultation

Early1900s Awarenessofutilityofearlydiagnosis andnewimagingtechniquesresultsin patientspresentingwithsmallertumors

Usually,rapidbrutalprocedures performedlateincourseofdisease; doesnotchangeultimateoutcome

Anesthesiaandaseptictechniqueallow earliersurgeryandbetteroutcomes; malignanttumorseasilyidentifiedby grossfeatures;radicalsurgical proceduresperformed

WilliamS.Halstedrequests intraoperativeconsultationon mastectomyspecimen

Grossexaminationnotsufficientto identifysmallertumorsasbenignor malignant;growingimpetusformore limitedsurgery;"Whencancerbecomes amicroscopicdisease,theremustbe tissuediagnosisintheoperatingroom"

(JosephColtBloodgood,1927)

Pathology

Capacitytoevaluatetumorsby microscopicexaminationnotavailable

Advancesinmicroscopy,microtomes, formalin,andtissuedyesallow identificationandclassificationoftumors

WilliamH.Welchperformsfrozen section,butprocedurerequiresanhour andresultsarenotavailableuntilafter operationhasbeencompleted

In1905,LouisB.Wilsonpublishesfrozen sectiontechniquethatcanbeperformed inafewminutes

Current Screeningandmodernimaging modalitiesdetectmanycancersatearly stage;canceristrulymicroscopic diseaseformanypatients

Modernsurgeryminimizestissue removedtomaintainfunctionand optimizecosmesis

–Abbreviationsmayvaryamongspecialtiesandmaybe misunderstood

□Forexample,pathologistsunderstand"c/w"to mean"consistentwith,"whereasradiologists understand"c/w"tomean"comparedwith"

○Superfluousinformation(typicallyhistologictypeor grade)isunnecessaryandcancreatepotential discrepancieswiththefinaldiagnosis

○ Pearlofknowledge:Itiscriticaltoknowthe consequencesofadiagnosis(e.g.surgeryforpotential cureterminatedorcontinued)whenmakingdiagnostic judgementcallswhenadefinitivediagnosisisnot obvious

–Theharmofafalse-negativevs.afalse-positive diagnosisforapatientisoftennotequivalent

•Copyofreportismadeandprovidedforpatient'smedical record

•WrittenreportsofIOCmaynotbeavailabletopatient's caregiversforhourstodays

○Whenpossible,documentationofIOCinmannerthatis availableinpatient'srecordispreferable

○Inelectronicmedicalrecords,thismaybepossibleusing holdnote

OralReport

•Finaldiagnosisiscalledbacktooperatingroom

○Itispreferabletoreadwrittenreportexactly

•Whenpossible,informationshouldberelayeddirectlyto surgeon

○ Pearlofknowledge:Complexorunusualdiagnosesare bestcommunicateddirectlybetweenpathologistand surgeon

–Thereishighrateofmiscommunicationwhen diagnosisisotherthan"benign"or"malignant"

Intraoperativediagnosisplaysimportant roleinprovidinginformationsurgeon needstoensuretumorshavebeen removedandmarginsareclear

–Reportsincludingtermsindicatingdegreesof certainty("suspiciousfor,""cannotexclude," "atypical")canbeinterpreteddifferentlyby pathologistandsurgeon

–Similarterms(e.g.,"carcinoid"and"carcinoma")must beclearlydistinguished

•Thepersonreceivinginformationshouldwritedown informationandreaddiagnosisbacktopathologist

○ThisisrequirementofTheJointCommission(TJC), formerly,TheJointCommissiononAccreditationof HealthcareOrganizations(JCAHO)

SELECTEDREFERENCES

1. NorganAPetal:Implementationofasoftwareapplicationforpresurgical casehistoryreviewoffrozensectionpathologycases.JPatholInform.8:3, 2017

2. SamsSBetal:Discordancebetweenintraoperativeconsultationbyfrozen sectionandfinaldiagnosis.IntJSurgPathol.25(1):41-50,2017

3. McIntoshERetal:Frozensection:guidingthehandsofsurgeons?AnnDiagn Pathol.19(5):326-9,2015

4. RoySetal:Frozensectiondiagnosis:istherediscordancebetweenwhat pathologistssayandwhatsurgeonshear?AmJClinPathol.140(3):363-9, 2013

5. WintherCetal:Accuracyoffrozensectiondiagnosis:aretrospectiveanalysis of4785cases.APMIS.119(4-5):259-62,2011

6. TaxyJB:Frozensectionandthesurgicalpathologist:apointofview.Arch PatholLabMed.133(7):1135-8,2009

7. GalAAetal:The100-yearanniversaryofthedescriptionofthefrozen sectionprocedure.JAMA.294(24):3135-7,2005

8. LechagoJ:Thefrozensection:pathologyinthetrenches.ArchPatholLab Med.129(12):1529-31,2005

9. AcsGetal:Intraoperativeconsultation:anhistoricalperspective.Semin DiagnPathol.19(4):190-1,2002

10.WrightJRJr:Thedevelopmentofthefrozensectiontechnique,the evolutionofsurgicalbiopsy,andtheoriginsofsurgicalpathology.BullHist Med.59(3):295-326,1985

Diagnostic pathology: intraoperative consultation 2nd edition susan c. lester - Read the ebook onlin

A

Dedication

Additional Contributing Authors

Acknowledgments

Lead Editor

Text Editors

Image Editors

Illustrations

Art Direction and Design

Production Coordinators

TABLEOFCONTENTS

SECOND EDITION

LESTER

IntraoperativeConsultation:Introduction

THEARTOFINTRAOPERATIVE CONSULTATION

MoreThanPathologyatHighSpeed

GoalsofIntraoperativeConsultation

IntraoperativeConsultation:Introduction

MostCommonDiagnosticQuestions

ChangesinIntraoperativeConsultationOverTime

Limitations

IntraoperativeConsultation:Introduction

REPORTINGRESULTS

WrittenReport

IntraoperativeConsultation:Introduction

HistoryofIntraoperativeConsultations

OralReport

SELECTEDREFERENCES