Frozen Section Dilemmas

[KeratinPearls]

Had a case where there were single atypical cells seen on frozen of a skin flap (patient was having a mastectomy). Patient had chemo for breast ca. Couldnt tell whether the atypical cells were malignant, due to chemo or due to cautery. We didnt call the cells malignant on frozen...I think we just said atypical.

Eventually, we called it atypia of undetermined significance on the report and placed a note that the atypia could possibly be due to cauterization since the atypical cells didnt conform to any architectureal pattern and the lobules in the final resection didn't show similar atypia (ruled out chemo effect as a possible cause).

You guys have any stories of frozen sectin dilemmas and how did it turn out?

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[KCShaw]

If you stare at a slide long enough, you'll likely find some individual odd looking cells. Especially frozens. Occasionally the company they keep may not quite make sense, the clinical story tickles your Spidey sense just enough, or they're just odd enough, and you have to go that non-specific-wtf-descriptive route. I've been trying to think of the specifics of such cases I had in the past, but they're just not coming to me at the moment. Perhaps because I tried to block them out. Plus, of course, it's been a while since I've been subjected to frozens.

 

[pathstudent]

I am a firm believer in undercalling frozen sections. It is much better to have the patient go back for another operation then to take **** out that can't be put back in.

I miss lobular carcinoma micromets in sentinel node frozen sections all the time, and I don't care. You can't ever see the stuff on frozen anyway.

Lastly, remember, don't ever ever ever freeze a lymph node for lymphoma. you just ruin the material and WTF would you ever need to make a diagnosis of lymphoma on frozen?

 

[green mantis]

I'm kind of curious. Why were you freezing a skin flap on a mastectomy? Did the surgeon send you more tissue? Was the flap even close to the tumor? If it wasn't, it's probably not a big issue. The surgeon can just follow it. Also, it's possible that the patient may get radiation.


----- Antony

 

[raspberry009]

I would have to disagree with "pathstudent."


Being it on the breast, an area where it won't hurt to take a little "extra" is more beneficial to the patient than missing it and having to go through another surgery again (add another gigantic bill and anxiety). Most people here would rather take more, depending on where on the body, rather than less. But! also what kind of atypia are you looking at?? SCCIS? - that can be frozen off (people in derm do it all the time). Pagets on the other hand...
we just had a med student give an excellent presentation of a patient with primary pagets of the vulva on a frozen section case. Very very VERY difficult on frozen. Yet, the consultant (or called an attending everywhere else) called it on frozen based on architectural disarray. They were maturing, but some cells just didn't "look right." I wish I could show you a pic. But anyway, cautery has a very distinct look ...typically (there are exceptions to every rule).

Hope that helps.

 

[raspberry009]

I am a firm believer in undercalling frozen sections. It is much better to have the patient go back for another operation then to take **** out that can't be put back in.

I miss lobular carcinoma micromets in sentinel node frozen sections all the time, and I don't care. You can't ever see the stuff on frozen anyway.

Lastly, remember, don't ever ever ever freeze a lymph node for lymphoma. you just ruin the material and WTF would you ever need to make a diagnosis of lymphoma on frozen?

I think you are selling yourself short. People can get good at frozen section and can see these things, granted yes you will miss a few, but that never means that you can practice and get better.

We will do frozen on sentinal lymphnodes and sometimes even I (a resident) can pick these things up (lobular, metastatic melanoma micromet, ect). I don't have enough fingers for the times where lyphoma was called on the frozen section where a patient was being staged for something else. Usually half the node is not frozen and can therefore be sent to flow. The frozen tissue (although the morphology maybe shot) is still available for IHC.

 

[pathstudent]

I would have to disagree with "pathstudent."


Being it on the breast, an area where it won't hurt to take a little "extra" is more beneficial to the patient than missing it and having to go through another surgery again (add another gigantic bill and anxiety). Most people here would rather take more, depending on where on the body, rather than less. But! also what kind of atypia are you looking at?? SCCIS? - that can be frozen off (people in derm do it all the time). Pagets on the other hand...
we just had a med student give an excellent presentation of a patient with primary pagets of the vulva on a frozen section case. Very very VERY difficult on frozen. Yet, the consultant (or called an attending everywhere else) called it on frozen based on architectural disarray. They were maturing, but some cells just didn't "look right." I wish I could show you a pic. But anyway, cautery has a very distinct look ...typically (there are exceptions to every rule).

Hope that helps.

I disagree with your disagreement. If you had an axillary dissection that was unnecessary and ended up with lymphedema, I think you would be pissed and ready and entitled to sue.

 

[KeratinPearls]

I think you are selling yourself short. People can get good at frozen section and can see these things, granted yes you will miss a few, but that never means that you can practice and get better.

We will do frozen on sentinal lymphnodes and sometimes even I (a resident) can pick these things up (lobular, metastatic melanoma micromet, ect). I don't have enough fingers for the times where lyphoma was called on the frozen section where a patient was being staged for something else. Usually half the node is not frozen and can therefore be sent to flow. The frozen tissue (although the morphology maybe shot) is still available for IHC.

Raspberry, I hear you at Mayo do frozens on everything? You guys stain the frozen with toludine blue? How does the Frozen section service work there, just curious?

Also, just as a learning point, how do you make a diagnosis of Paget's on frozen and differentiate it from the other differentials like melanoma?

 

[raspberry009]

It really depends on the consultant whether everything will get frozen.

I personally agree that not everything needs to get staged. Margins and tumor type I think are the most important. But some pathologists find it much easier to sign the case out on frozen. Most cases that are signed out at the frozen section do not required changed when we get the H&E the following day. Its our way of "proofreading" what we did the following day.

All frozens are stained with T. blue because it's quick (30 seconds) and easy. For frozen I think I may prefer it over H&E actually. We do H&E frozen in the derm dept.

 

[deleted314957]

Prime example of narrow-midedness. I almost don't even want to justify this with an explanation. This statement is archeic and ignorant.

Sure pathologists can take their sweet time on making a diagnosis. I'm sure in most places it can take over a week to make a diagnosis. But let's take a moment to think about the patient. Sure you can say "it won't matter" and in the long run your probably right. But why do that when it's not necessary? Why cause prolonged anxiety when it's not needed?

Say this was YOUR cancer. You just had your prostate taken out for adenocarcinoma. The following day the surgeon tells you that you might also have lymphoma in your inguinal lymph nodes that were oringally taken out for staging. Here, we can get that result to you that afternoon, in most cases, or the next day. Do you want to wait a week to get your results??

It's so easy for you to pass judgement, but you cannot say that you would want not it faster if that were an option.

I suppose its people like you that keep Mayo in business. Patients come here because they will have this option. So thank you for keeping us in business.

Raspberry, there is one HELL of a big difference between a result "that afternoon" and "waiting a week". 98% + of my cases are 24 hour turn around, frozen or not. I STRONGLY discourage the use of a frozen section unless an immediate intra-operative decision is going to be based on the result. I think the frozen section of convenience is to be wasteful and in some cases negligent.

 

[raspberry009]

Raspberry, I hear you at Mayo do frozens on everything? You guys stain the frozen with toludine blue? How does the Frozen section service work there, just curious?

Also, just as a learning point, how do you make a diagnosis of Paget's on frozen and differentiate it from the other differentials like melanoma?

It's really like learning on H&E. You get a feel for what different tumors look like. After you get burned a couple of times, you learn. A lot of consultants won't call Pagets on T. blue. But the ones with a lot of experience will. Then the older consultants get out there, it's amazing what rare diagnoses they will call and their right most of the time!

Its all about getting familiar with the method. When cytology first came out everyone was calling everything benign because how in the world can you call anything by single cells without architecture??? But over time as you become familiar with it and learn to differentiate the minutia.

 

[levels x3]

Agree with mikesheree. The only reason to do a frozen section is to answer a question that will change the operative course. As far as my experience has been, this seems to be the widely prevailing opinion as well.

 

[raspberry009]

Raspberry, there is one HELL of a big difference between a result "that afternoon" and "waiting a week". 98% + of my cases are 24 hour turn around, frozen or not. I STRONGLY discourage the use of a frozen section unless an immediate intra-operative decision is going to be based on the result. I think the frozen section of convenience is to be wasteful and in some cases negligent.

There is much debate about this very topic amung consultants. But most surgeons perfer it this way. They do not have to have their tissue frozen if they do not want to, but surprisingly enough, surgeons like to have a diagnosis for the patient when they wake up (who would have thunk?). Some cases don't even leave the OR without radiation, sentinal lymph node, axillary dissection, ect. Because of this, surgeons have a lot of flexibility as far as treatment on a regular bases. They become familiar with us and us with them (first name basis actually). It allows them to think outside the box and take everything to the next level. They do get pissed when we say we were wrong the following day. Frozens may not be required, but they sure are convenient, on multiple levels.

I'm glad that you bring up turnaround time and percentage correct. We do this here as well and in comparing our ability to make the right diagnosis on frozen is above the national average (what's been published anyway) because we do this, every day, all the time.

I'm glad that you are completely satisfied with your work and the hospital is satisfied with your work. Like you, I will be looking for a job as an attending in the real world as well. Although Mayo does seem like it's own world, I won't be here forever. But I have a lot of great ideas on how to improve patient care and push people out of their confort zone.

Can we exchange ideas freely and not get pissed off? After all, I went into patient care to change lives and make a difference. I am trained in traditional pathology as well and have a lot to bring to the table.

For example why not use RFIP for specimen tracking? You can not only identify the sample, but track where it's been and how long it took to process from start to finish, AND dramatically decrease sample mixup. Which instrument do you need? When patients are waiting for phlebotomy, what can we do to speed up that time so they are not waiting longer than 5 minutes during "rush hour"? Are you happy with your H&E? Because I can make it better. Not so pink or blue. Why do you get bloches on your slide where it's just pink? is it because the tech is carrying over the xylene from the alcohols and the hematoxylin is insoluable with xylene and therefore can't stain the slide whereas eosin is soluable which results in the pink slide...
Let's think outside the box. Sure some ideas are a flop but some may change the way that you practice medicine for the better.

I realize that frozen section is practiced differently where ever you are. Here patients and surgeons expect that we deliver our results as soon as humanly possible, and what we do works for us. It may not work for you and your hospital. Frozen may not be as easy because you don't do it all the time or it's not practical for the work load. But it is not "neglect."

 

[2121115]

Had a case where there were single atypical cells seen on frozen of a skin flap (patient was having a mastectomy). Patient had chemo for breast ca. Couldnt tell whether the atypical cells were malignant, due to chemo or due to cautery. We didnt call the cells malignant on frozen...I think we just said atypical.

Eventually, we called it atypia of undetermined significance on the report and placed a note that the atypia could possibly be due to cauterization since the atypical cells didnt conform to any architectureal pattern and the lobules in the final resection didn't show similar atypia (ruled out chemo effect as a possible cause).

You guys have any stories of frozen sectin dilemmas and how did it turn out?

I am a high powered expert academic pathologist and there is NO SUCH THING as a frozen section dilemma for me! There are only dilemmas for non-expert community pathologists! I know every answer because whatever I say is the right answer! I don't consult shiit with nobody and I am never wrong!

Ooops, I'm sorry I didn't mean to speak for pathstudent....

 

[BierstiefelAndy]

I am a high powered expert academic pathologist and there is NO SUCH THING as a frozen section dilemma for me! There are only dilemmas for non-expert community pathologists! I know every answer because whatever I say is the right answer! I don't consult shiit with nobody and I am never wrong!

Ooops, I'm sorry I didn't mean to speak for pathstudent....

Touche

I'll follow suit...in cytology, I have now decided to stop calling things atypical or suspicious....only negative or malignant! yeeeeehawwww!

 

[yaah]

I am still trying to think of a good response to the gyn onc surgeon who complains whenever I tell her that the tumor she sent down is a "mucinous neoplasm." I hate mucinous tumors on frozen. I had one last week where the first section I took was completely benign but since it was so big I took a second and it had cancer. Then she wanted to know where it was coming from. I can never answer her questions fully. I could tell her it was clearly a malignant primary ovarian mucinous carcinoma and she would still come up with a question.

 

[KCShaw]

I don't think a place (or individual) consistently miscalling things on frozen is going to keep trying to do so. Patients, surgeons, lawyers, chairmen, and administrators really don't like that sort of thing -- especially if it's leading to additional dissections or radiation the same day (or the same not being done when it could have been). I assume the Mayo practice is pretty well validated (this would be a good point of interest -- hit & miss numbers, not just the obvious bonus of turnaround time, which to some extent could be considered a fair trade for "some" increased day 0 error), though also probably pretty difficult to get into from the outside, most people not having that sort of frozen exposure. But simply being quite different from most people's experience, perhaps even radically so, doesn't appear to be relevant.

Sounds to me like that gyn onc needs to spend a couple of weeks in the path department. Those are the kinds of questions that imply to me they have no idea what we can/can't do and what we would tell her if we really knew. Of course, there are also those people, who seem to be relatively common in medicine, who will continue to ask you questions until you have no more answers -- it's a competitive smarter-than-thou psychological thing and I suppose helps them sleep better at night. We breed it in med school and residency, and is very hard to beat out of people later on -- though they can occasionally raise interesting points for debate, like why we can't/don't answer a certain question which perhaps we could/should (or why bother answering certain questions which are currently meaningless).

 

[deleted314957]

I am still trying to think of a good response to the gyn onc surgeon who complains whenever I tell her that the tumor she sent down is a "mucinous neoplasm." I hate mucinous tumors on frozen. I had one last week where the first section I took was completely benign but since it was so big I took a second and it had cancer. Then she wanted to know where it was coming from. I can never answer her questions fully. I could tell her it was clearly a malignant primary ovarian mucinous carcinoma and she would still come up with a question.

i don't get many of these huge balls of goo but when i do i tell them that" i have taken my frozen from the grossly most worrisome area of the tumor and we are dealing with AT LEAST a borderline mucinous tumor but that i must do many more permanent sections and cannot assure i will not find areas of frank malignancy" (example answer, of course). I have never had a complaint with this kind of response. It helps that I have been here 20 years and have some creds with the surgeons though. Your surgeon just sounds like a jerk.

 

[raspberry009]

Most cases where there is a difference between the frozen and final here are undercalled. I can only think of one time where a case was called cancer when it wasn't with big consequence. I'm sure there are others, but it doesn't happen very often.

In cases where the call is tough, the pathologist will actually walk down to the OR and have a discussion with the surgeon. They will discuss what the next step whould be. i.e. can the surgeon submit more tissue or would be better to close up and wait for results the following day.

In cases that are undercalled there are multiple scenarios:
1) Invasion was missinterpreted - rare on T. blue because invasion turns pink (one of the reasons why I prefer T. blue over H&E). T.blue is pink in cartilage and metastasis as well. One cancer where T. blue is consistantly blue is prostate.
2) It wasn't on the sections that were the frozen was cut but is now on the H&E the following day.
3) Location - anatomy. Is it a case where if you're on the fense can you take more without a problem or do you need to be conservative?

Cases that are overcalled:
1) Location - taking extra tissue to get a clear margin would outweigh the consequence of leaving tumor behind.
2) Missinterpretation

There are probably more reasons, but these are the biggies that I can think of.

 

[zao275]

Your surgeon just sounds like a jerk.

Either that or very ignorant (as suggested by KCShaw). Both options sound highly frustrating. You know, yaah, you could make a cartoon video about this and post it on youtube. It's a fun way to vent. Maybe the surgeon will see it and get the picture. Ok, just kidding. ;-) But I would love to see it.

Make cartoon videos here: http://www.xtranormal.com/. Easy to do. Just type in the words and it does the rest (essentially).