The value of the intraoperative assessment of the SLN via frozen section in the post Z0011 era

INTRODUCTION

Sentinel node (SN) assessment via frozen section (FS) has declined since the publication of Z0011 which modified the management of a specific group of patients with positive SN. The risk of misleading the surgeons to a preventable ALND and the cost are among the main factors for that. The aim of our study is to assess the value of FS in the post Z0011.

MATERIAL AND METHODS

244 patients out of 434 were eligible for an upfront SLNB. Based on the final histology and the clinical data we selected the eligible for breast conserving surgery patients (55.4%). 78 patients had positive SN and 26 of them fulfilled the criteria of Z0011. We assessed the false negative findings, the impact on the management and the indications and value of FS in the post Z0011 era.

RESULTS

Overall, there were 12 FN cases out of which 7 were macrometastases (8.97%). Only in one case there were > 2 positive LN and 3 patients needed mastectomy. The remaining cases fulfilled the criteria of Z0011 and needed no further surgery hence in 96.1% of the cases the axillary status was correctly assessed via FS and the reoperation rate was 1.2%. On the contrary, if FS was not used, at least 21.3% of the patents would have needed reoperation based on the today's guidelines.

DISCUSSION

We believe FS is still valuable and may spare a significant percentage of patients from a second operation (SNB) without leading to axillary overtreatment if used wisely.

Circulating Sex Steroid Measurements of Men by Mass Spectrometry Are Highly Reproducible after Prolonged Frozen Storage

Long-term studies investigating hormone-dependent cancers and reproductive health often require prolonged frozen storage of serum which assumes that the steroid molecules and measurements are stable over that time. Previous studies of reproducibility of circulating steroids have relied upon flawed historical rather than contemporaneous controls. We measured serum testosterone (T), dihydrotestosterone (DHT), estradiol (E2) and estrone (E1) in 150 randomly selected serum samples by liquid chromatography-mass spectrometry (LC-MS) from men 70 years or older (mean age 77 years) in the CHAMP study. The original measurements in 2009 were repeated 10 years later using the identical serum aliquot (having undergone 2-4 freeze-thaw cycles in the interim) in 2019 together with another never-thawed aliquot of the same serum sample. The results of all three sets of measurements were evaluated by Passing-Bablok regression and Bland-Altman difference analysis. Serum androgens (T, DHT) and estrogens (E2, E1) measured by LC-MS display excellent reproducibility when stored for 10 years at -80 C without thawing. Serum T and DHT displayed high level of reproducibility across all three sets of measurements. Multiple freeze-thaw cycles over those storage conditions do not significantly affect serum T, DHT and E1 concentrations but produce a modest increase (21%) in serum E2 measurements.

Frozen sections in patients undergoing breast conserving surgery at a single ambulatory surgical center: 5 year experience

OBJECTIVES

To evaluate outcomes of our breast frozen section (FS) practice in its first 5 years, including our specialized FS of margins (FSM) procedure for breast conserving therapy (BCT) patients.

METHODS

One thousand two hundred and forty eight patients undergoing 1303 breast FSM and/or sentinel lymph node (SLN) FS were included. Clinicopathologic features were assessed by chart review.

RESULTS

Use of SLN FS declined, from 43.5% of FS cases before to 19.2% of FS cases after 2012. FSM patients had a decline in overall reexcision to 12.3% in 2013-2014 (p = 0.063). There was also decline in reexcision for focally close margins (p < 0.0001) but no change in reexcision for extensively close margins. Reexcision was significantly associated with lobular subtype, multifocality and larger (≥T2) size. False negative FSM cases were most often influenced by extensively close or positive final (reexcised) margins sent for permanent section only (96/148; 64.9%).

CONCLUSIONS

Despite changing surgical practices, FSM remains a valuable service that reduces reexcision in BCT patients.

Intraoperative Frozen Section Histology: Matched for Musculoskeletal Infection Society Criteria

BACKGROUND

The current gold standard to diagnose periprosthetic joint infection (PJI)-the Musculoskeletal Infection Society (MSIS) criteria, requires a battery of tests, the results of which may not be available at the time of decision-making. Thus, surgeons often rely on intraoperative frozen section histology. However, the accuracy of frozen sections has not been determined when matched for the MSIS criteria. We aimed to (1) assess the value of intraoperative histology in the diagnosis of PJI and (2) evaluate discrepancy rate between frozen and permanent section analysis.

METHODS

A retrospective review of patients who underwent revision total hip or total knee arthroplasty for either PJI or mechanical failure in 2013 was conducted. Two hundred procedures where tissue samples for frozen sections had been collected were identified and included into the study. Results of frozen sections were compared to the modified MSIS criteria. Discrepancy rate between frozen and permanent sections was also calculated.

RESULTS

Frozen sections had sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 73.7% (95% confidence interval [CI], 59.7%-87.7%), 98.8% (95% CI, 97.1%-100.0%), 94.1% (95% CI, 90.6%-97.6%), 93.3.4% (95% CI, 84.4%-100.0%), 94.0% (95% CI, 90.7%-97.3%), respectively. There were 10 discrepancies between the results of frozen and permanent sections (N = 421 samples), thereby yielding 97.6% concordance.

CONCLUSION

When matched to the MSIS criteria, intraoperative frozen section histology yields a high specificity, positive predictive value, negative predictive value, accuracy, and moderate sensitivity. The discrepancy rate between frozen and permanent sections is low and both demonstrate good approximation of MSIS criteria.

Sentinel Lymph Node Frozen-Section Utilization Declines After Publication of American College of Surgeons Oncology Group Z0011 Trial Results With No Change in Subsequent Surgery for Axillary Lymph Node Dissection

OBJECTIVES

To evaluate use of sentinel lymph node (SLN) frozen section (FS) before and after publication of the Z0011 trial.

METHODS

We identified 116 pre-Z0011 and 134 post-Z0011 patients from 18 months before and after Z0011-initiated changes. Clinicopathologic features were assessed by chart review.

RESULTS

Post-Z0011 SLN FS use markedly declined when performed with breast-conserving therapy (BCT) (P < .0001), with SLN FS in 53 (73.6%) of 72 and 19 (25.0%) of 76 in pre- and post-Z0011 groups, respectively. There was post-Z0011 decline in axillary lymph node dissection (ALND) (P = .014) but no difference in later procedures for ALND. SLN positivity was associated with larger (≥1.6 cm) tumor size (P = .002). Nodal upstage was more frequent with invasive lobular (3/32; 9.4%) vs other invasive (2/188; 1.1%) subtypes.

CONCLUSIONS

Our findings support reduced need for SLN FS for BCT patients post-Z0011. However, those with specific clinicopathologic features may derive greater benefit from SLN FS.

Establishing an accurate diagnosis of a parotid lump: evaluation of the current biopsy methods - fine needle aspiration cytology, ultrasound-guided core biopsy, and intraoperative frozen section

The optimum technique for histological confirmation of the nature of a parotid mass remains controversial. Fine needle aspiration cytology (FNAC), which has traditionally been used, is associated with high non-diagnostic and false negative rates, and ultrasound (US)-guided core biopsy and frozen section have been explored as alternatives. US-guided core biopsy is more invasive than FNAC, but is safe, well-tolerated, and associated with improved diagnostic performance. Although frozen section offers better specificity than FNAC, it has a number of important drawbacks and cannot be considered as a primary diagnostic tool. US-guided core biopsy should be considered as the initial diagnostic technique of choice, and in units where the accuracy of FNAC is good it can be used when FNAC is equivocal or non-diagnostic.

Intraoperative consultation in digestive surgery. A consecutive series of 800 frozen sections

AIM

To assess indications and quality of frozen sections in digestive surgery.

PATIENTS AND METHODS

All the frozen sections from the department of digestive surgery from Amiens hospital performed between 01/07/2006 and 01/07/2010 were assessed. Assessment of frozen section forms, reading of pathology reports, and reviewing of frozen section slides were performed.

RESULTS

Eight hundred frozen sections were performed in 349 patients. From one to 14 surgical specimens were sent for frozen section (mean 2.3). Frozen sections were performed in 77% of the cases for cancer surgery (n=268), most of the time pancreatic surgery (28.4%) and liver surgery (24.6%). Frozen sections were performed in 69% of the cases for diagnosis, in 29% of the cases to assess surgical margins and in 2% of the cases to assess if tissue specimen was appropriate for pathological diagnosis. Frozen sections were sent all days of the week (except Saturday and Sunday), during all the year, between 8 H 30 and 17 H 15. Thirty-seven percent of the cases were sent between 12 H and 14 H. Response time was 15 minutes (3 to 57 minutes). Rate of differed diagnoses was 2%. Rate of discordant diagnoses was 3.4%.

CONCLUSION

Frozen section is a rapid and accurate tool in digestive surgery. Local adjustment of the organization of the Pathology Department could enhance the rapidity and the quality of pathology diagnoses.

Intra-operative frozen section technique for breast cancer: end of an era

Data on 2436 primary breast carcinomas diagnosed between 1992 and 2006 were collected to evaluate the rate of frozen section procedures performed over time. Frozen section procedures performed to evaluate resection margins for conservative surgery or sentinel node status were excluded. Over time, there was a decrease in the use of frozen sections indistinctly extended to all pT cancer categories. The rate of cancers diagnosed with frozen sections was 51.2% in 1999, and 0% in 2005-2006. In the same period, the adoption of cytology and core biopsy for breast cancer diagnosis increased from 40% in 1992 to more than 90% since 1999. In an audited diagnostic activity on breast pathology, the routine use of frozen sections on primary lesions was considered inappropriate, particularly in assessment of clinically non-palpable lesions, and should be limited to cases with inadequate pre-surgical sampling.

Is There an Indication for Frozen Section Examination of the Ureteral Margins During Cystectomy for Transitional Cell Carcinoma of the Bladder?

PURPOSE

We evaluated the incidence of pathological findings of the ureter at cystectomy for transitional cell carcinoma of the bladder and assessed the usefulness of intraoperative frozen section examination of the ureter.

MATERIALS AND METHODS

Histopathological findings of ureteral frozen section examination were compared to the corresponding permanent sections and the diagnostic accuracy of frozen section examination was evaluated. These segments were then compared to the more proximal ureteral segments resected at the level where they cross over the common iliac arteries. The histopathological findings of the ureteral segments were then correlated for upper urinary tract recurrence and overall survival.

RESULTS

Transitional cell carcinoma or carcinoma in situ was found on frozen section examination of the distal ureter in 39 of 805 patients (4.8%) and on permanent sections in 29 (3.6%). In 755 patients the false-negative rate of frozen section examination of the ureters was 0.8%. Of the patients with carcinoma in situ diagnosed on the first frozen section examination 80% also had carcinoma in situ in the bladder. Transitional cell carcinoma or carcinoma in situ in the most proximally resected ureteral segments was found in 1.2% of patients. After radical cystectomy there was tumor recurrence in the upper urinary tract in 3% of patients with negative ureteral frozen section examination and in 17% with carcinoma in situ on frozen section examination.

CONCLUSIONS

Routine frozen section examination of the ureters at radical cystectomy is only recommended for patients with carcinoma in situ of the bladder, provided the ureters are resected where they cross the common iliac arteries.

Surgical margin determination in head and neck oncology: current clinical practice. The results of an International American Head and Neck Society Member Survey

BACKGROUND

Our aim was to investigate the ways in which surgeons who perform head and neck ablative procedures on a regular basis define margins, how they use frozen sections to evaluate margins, and the effect of chemoradiation on determining tumor margins.

METHODS

A custom-designed questionnaire was mailed to members of the American Head and Neck Society asking members how they evaluate and define tumor margins.

RESULTS

Of 1500 surveys mailed, 476 completed surveys were received. The most common response for distance of a clear pathologic margin was >5 mm on microscopic evaluation. A margin containing carcinoma in situ was considered a positive margin by most, but most did not consider a margin containing dysplasia a positive margin. When initial frozen section margins are positive for tumor and further resection results in negative frozen section margins, 90% consider the patient's margin negative. Most surgeons sample the frozen section from the surgical bed rather than from the main specimen. Nearly half use wider margins when resecting tumors treated with neoadjuvant therapy. When resecting recurrent or residual tumors treated with previous chemoradiation therapy, most resect to the pretreatment margin.

CONCLUSIONS

No uniform criteria to define a clear surgical margin exist among practicing head and neck surgeons. Most head and neck surgeons consider margins clear if resection completed after an initial positive frozen section margin reveals negative margins, but this view is not shared by all. Most surgeons take frozen sections from the surgical bed; however, error may occur when identifying the positive margin within the surgical bed. The definition of a clear tumor margin after chemoradiation is unclear. These questions could be addressed in a multicenter prospective trial.

[Ovarian tumours--accuracy of frozen section diagnosis]

A retrospective study of 450 ovarian biopsy results were examined for the period of 1998 till 2004 to evaluate the accuracy of frozen section diagnosis. In addition to this we performed a review of the literature for all previous studies in this field in order to study the accuracy rates of the different clinics throughout the world. The histhopathological results of the frozen section diagnosis were equal with the diagnosis of the paraffin blocks in 90%. The sensitivity rates for benign, malignant and borderline tumours, were 96%, 84% and 60% respectively. We had 10 patients (2,1%) false-positive results (overdiagnosed) and 26 (5,2%) false-negative results (underdiagnosed) in frozen section examinations. Frozen section examination of mucinous tumours showed hogher underdiagnosis--18%. The review of the literature showed that there is no significant difference in accuracy rates of frozen section diagnosis for benign and malignant ovarian tumours in relation with time. We found low accuracy rates for borderline tumours which was similar with most of the foreign publications. However the accuracy of the frozen section diagnosis is bettering with the time. As a result of this we conclude that the accuracy rates of the frozen section diagnosis for evaluation of the malignant and benign tumours is quite enough for correct diagnosis. Since accuracy rates for borderline ovarian tumours are low we have to take care and attention of improvement in this field.

Frozen section in thyroid surgery: is it a necessity?

INTRODUCTION

Many surgeons use intraoperative frozen-section (FS) biopsy of thyroid nodules to predict malignant disease, but the findings are often not in agreement with those of fine-needle aspiration (FNA) biopsy. Our objective in this study was to assess the value of intraoperative FS biopsy in patients with nodular disease of the thyroid gland.

METHODS

In this study, 203 patients underwent thyroid surgery at the Ankara Oncology Hospital. Nodules were assessed by FNA biopsy preoperatively, by FS intraoperatively and by histologic examination of the excised specimen. Sensitivity, specificity and accuracy were determined for FS and FNA with respect to the histologic findings.

RESULTS

The sensitivity, specificity and accuracy rates for FNA, excluding occult cancers, were 74.1%, 100% and 95.2%, respectively, and for FS were 87.1%, 100% and 97.8%, respectively. FS influenced operative decisions in 0.6% of nodules found to be benign by FNA and in 20% of nodules found to be suspicious by FNA. FS contributed nothing for FNA-malignant disease since all the results in this group were true positive.

CONCLUSIONS

Intraoperative FS was most helpful when the FNA findings were suspicious for malignant disease. FS does not seem to be necessary when FNA indicates malignant or benign disease. Both FNA and FS failed to detect occult thyroid carcinomas.

[Quality control in pathological anatomy: 10 years' experience]

The quality assurance scheme in use at the Section of Anatomic Pathology of the University of Bologna-Bellaria Hospital is described. Since 1992 a quality assurance (QA) scheme has been set up in this Institution. The scheme and results have been reported in this same Journal previously 1-3: here are reported the changes to the scheme that have intervened in the last four years. All data collected from January 1999 to December 2002 have been reviewed for monitoring the laboratory performance. Emphasis has been given to changes that have been introduced recently to improve QA.

[Benchmarking in pathological anatomy]

Data from five different Institution of Pathological Anatomy Hospital Services are presented in order to show one (the benchmark) of the multiple existing ways to approach the budget problem and the macroeconomic management of our Services. The aim of this work is not to show the "best" way to work in terms of cost-efficacy but only a methods to compare our results with others. Nevertheless from this study is possible also to make some considerations about medical and technical workload in different services with different habits.

Is thyroid frozen section too much for too little?

BACKGROUND

The role of frozen section (FS) in thyroid disease is controversial. The goal of this study was to identify a cohort of patients who may or may not benefit from FS.

METHODS

Two hundred thirty-one patients who underwent thyroidectomy were evaluated in regard to fine-needle aspiration (FNA), FS, and the extent of surgery.

RESULTS

In all, 155 patients underwent FNA, 140 patients underwent FS, and 103 patients had both. A final diagnosis of malignancy was obtained in 47 of 231 patients. FNA had a sensitivity of 50% and a specificity of 99%, and FS had a sensitivity of 50% and a specificity of 100% for diagnosing malignancy. Accounting for the clinical findings and FNA results, FS results altered the extent of thyroidectomy in 1 of 103 patients.

CONCLUSIONS

The increased costs for the operative time and the pathologists needed to obtain routine FS are not supported with any substantial benefit in patient outcome.

Accuracy of frozen section diagnoses of breast lesions after introduction of a national programme in mammographic screening

AIMS

By introducing mammography screening programmes, the size of the detected breast lesions became smaller and the histopathological interpretation problems greater. The study's aim was to analyse the risks and possible limitations of the frozen section method.

METHODS AND RESULTS

Frozen section consultations of breast lesions (n=559) 2 years before and 6 years after launching a national mammographic screening programme in 1992 were evaluated in regard of the benign/malignant ratio, tumour size, preoperative frozen section results and final permanent section diagnoses. The breast frozen section examinations of 1990 compared with those from 1998 declined from 70.7% (299/423) to 62.2% (260/418) (P < 0.01), the benign/malignant ratio from 1.09 to 0.54 (P < 0.0001), the rate of the conclusive, correct frozen section diagnoses from 96.3% to 91.9% (P < 0.03). The sensitivity dropped from 92.3% to 87.6%, the negative predictive value from 95.7% to 88.3%, whereas the negative likelihood ratio rose from 0.08 to 0.12. The 'small' (< or = 10 mm) invasive breast carcinomas increased from 14.2% to 22.3% (P < 0.01) and the 'in situ' carcinomas from 2.1% to 6.6% (P < 0.05).

CONCLUSIONS

The declining sizes of breast tumours (< or = 10 mm), especially from radiologically detected lesions and sometimes without a macroscopic correlate, create new limitations and changing indications in the histopathological interpretation. Considering the performance of new diagnostic methods (i.e. large core needle biopsies), frozen sections of surgical specimens should not be the primary diagnostic procedure for breast lesions and should be performed only after other preoperative methods have failed.

[Frozen section biopsy in the assessment of organs for transplantation]

BACKGROUND

The success of transplantation and the increase in its indications has caused organ donations to be unable to meet the global demand. By broadening the donor selection criteria and accepting so-called suboptimal donors in an attempt to solve this problem, a careful individualized assessment is required of the validity of each donor. This often implies the need for a pretransplantation biopsy study.

MATERIAL AND METHODS

Evaluation of frozen-section biopsy studies in the assessment of graft and donor validness in the the transplantation program of the La Fe University Hospital (Valencia, Spain) during 1998, when a total of 301 solid organ transplantations were performed.

RESULTS

Sixty pretransplantation frozen-section biopsies were performed (29 of the liver, 21 renal, 3 lymph nodes, 3 brain, 2 prostatic, 1 myometrial and 1 pericardial). As a result of the bioptic study, 18 transplantations were invalidated (30% of all biopsies). The most frequent causes of invalidation were liver macroesteatosis (7 cases), malignancies (5 cases) and renal parenchymal lesions (5 cases). Among the tumor diagnosis there were one false-positive and one false-negative results of malignancy.

CONCLUSION

Frozen-section biopsies evaluation in suboptimal organ donors or donors suspected of suffering disease integrates morphological analysis in the transplantation team decision process, and affords a quality factor in the selection of donors.

Frozen section analysis in the management of skin cancers

Frozen section analysis is used routinely to ensure complete removal of basal cell and squamous cell carcinomas of the skin, but the current emphasis on controlling costs raises the question as to which lesions should be evaluated with frozen section histology. A retrospective study of the clinical records and pathological reports of 51 patients selected randomly from a total of 225 patients was undertaken to determine the overall impact of frozen section analysis on the surgical management of skin cancers at this institution. The results indicate that frozen section analysis was performed on 76% of the 277 lesions evaluated, and that the results of frozen section examination were 91.1% accurate in detecting the presence or absence of tumor involvement at the surgical margins. The data also showed that the surgeons were able to estimate the margin of the skin tumor clinically and remove it entirely during the first excision 91.1% of the time. The lesions that had not been removed completely with the initial excision were those located on the periorbital region, forehead, and cheeks; were recurrent lesions; or were lesions that required more involved reconstruction than primary closure. This study shows that frozen section analysis is a valuable tool in selected situations, but routine use is not indicated for the majority of basal and squamous cell carcinomas of the skin.

The current status of surgical staging of ovarian serous borderline tumors

BACKGROUND

The purpose of the current study was to evaluate the current practice of surgical staging of ovarian serous borderline tumors.

METHODS

Women with a diagnosis of ovarian serous borderline tumors whose pathology slides were sent to the M. D. Anderson Cancer Center for second-opinion diagnostic consultation between 1990-1996 were identified. The original pathology reports and M. D. Anderson Cancer Center consultation reports of 255 cases were reviewed for the frequencies of frozen-section analyses and staging biopsies, biopsy results, the specialty of the surgeon, and hospital type.

RESULTS

The majority (78%) of ovarian borderline tumors primarily were encountered and staged by general obstetrician-gynecologists. Overall, 66% of patients had at least 1 staging biopsy performed. Approximately 12% of subjects underwent complete surgical staging, defined as having biopsy samples taken from pelvic and abdominal peritoneum, omentum, and retroperitoneal lymph nodes. Gynecologic oncologists performed complete staging in 50% of cases, obstetrician-gynecologists performed complete staging in 9% of cases, and general surgeons performed complete staging in 0% cases. The overall frequency of a positive staging biopsy was 37%. Approximately 47% (80 of 169) of patients who underwent biopsies were upstaged as a result of positive biopsies, - with 41% (70 of 169) having extrapelvic spread.

CONCLUSIONS

Currently, surgical staging for women with ovarian serous borderline tumors remains inadequate, although a significant proportion of patients who undergo staging are noted to have extrapelvic spread.

Relative accuracy of fine-needle aspiration and frozen section in the diagnosis of well-differentiated thyroid cancer

The need for and extent of thyroid surgery for a thyroid nodule is usually primarily based on fine-needle aspiration (FNA) and frozen section diagnosis. The relative role of these modalities in 66 patients who had undergone FNA and subsequent thyroidectomy with frozen section was investigated. Cases that demonstrated discordance between FNA and frozen section (n = 22; 33%) were identified, and all slides were re-reviewed by a cytopathologist using current established cytologic criteria. A change in diagnosis was made in 13 cases with an increase in accuracy of FNA from 71% to 88%. The accuracy of frozen section (92%) did not change appreciably with re-review (94%). The accuracy of FNA and frozen section combined was found to be 98%. The rate of discordance decreased from 33% to 13% with re-review. When strict histologic and cytologic criteria are applied, FNA and frozen section are accurate and complementary methods that help in determining the operative management of thyroid masses. However, when FNA yields a diagnosis of "follicular neoplasm," frozen section is unlikely to change this diagnosis.

[Weighted kappa statistics for measuring the divergence of rapid section and definitive diagnosis]

Weighted Kappa statistics measure or quantify the disagreement between diagnoses given by different observers or which were established in different time periods. The study reports on 2226 frozen-section examinations performed in the period of 1986 to 1995 at the Pathology Institute of Neuchâtel, Switzerland. The two cohorts formed by the "first diagnosis" and the "definitive diagnosis" are classified in four SNOMED Morphology categories and, in case of disagreement, the weight of the error is computed according to an arbitrary scheme of 2 to 20 points. Of the diagnoses 2093 (= 94.0%) were completely identical. The kappa of the cohort is 0.91 (+/- 0.008), the weighted kappa 0.95 (+/- 0.005). Analyses of different parameters show a constantly higher value for weighted kappa than for nonweighted kappa. The 133 cases with disagreements reveal, among others, that frozen-section examination of the thyroid gland has a high risk of error, whereas biopsies of the mammary gland give the best results (rare and practically no significant disagreement). Subsequent analyses investigate diagnostic quality according to the chronological evolution and the performance of the responsible pathologists.

Accuracy of frozen sections in assessing margins in oral cancer resection

PURPOSE

This study examined the accuracy of frozen section diagnosis of tissue samples from surgical margins compared with the final histologic diagnosis of the same tissue. The total resection specimen was also examined to see whether frozen sections were helpful in predicting negative margins for the entire cancer. The nature of positive and negative margins and their implications for the surgeon are discussed.

PATIENTS AND METHODS

The records of 49 consecutive patients with previously untreated squamous carcinoma of the mouth were reviewed. All frozen and permanent sections were evaluated by one pathologist. Margins involved by carcinoma, carcinoma in situ, dysplasia, or with carcinoma within 5 mm were defined as positive. Histologic findings were compared with the patient's clinical course to define the relationship between positive margins and local recurrence. Patients were followed for 17 to 45 months or until death.

RESULTS

Three hundred four of 307 frozen sections showed concordance with the permanent section of the same tissue sample (two false negative and one false positive), an accuracy rate of 99%. When the final margins of the resected surgical specimen were compared with the frozen section diagnoses, ten patients had positive final margins. In three patients, these were diagnosed by frozen section. Seven patients had final margins that were positive when the surgical resection specimen was examined but were not diagnosed by frozen section. A greater local recurrence note was found in patients with invasive carcinoma at the margin, dysplastic margins, and margins within 5 mm of the cancer.

CONCLUSIONS

Although frozen sections are extremely accurate, they are not as reliable in eliminating positive margins in the final specimen as the surgeon might hope.

Interinstitutional comparison of frozen section turnaround time. A College of American Pathologists Q-Probes study of 32868 frozen sections in 700 hospitals

OBJECTIVES

To study the intraoperative turnaround time for performing a frozen section (FS) and to examine pathology practice variables that influence it.

DESIGN

Over a 4-month period in 1995, participants in the College of American Pathologists Q-Probes laboratory quality improvement program prospectively collected data on up to 30 FS procedures performed on elective inpatient surgical cases and completed questionnaires profiling their FS practice characteristics.

SETTING

Surgical pathology laboratories serving private and public hospitals.

PARTICIPANTS

Seven hundred institutions located in North America (667), Australia (12), New Zealand (1), the United Kingdom (3), Hong Kong (1), Mexico (1), and Norway (1).

MAIN OUTCOME MEASURES

The 90% FS block completion time defined as the time interval, in minutes, within which the fastest 90% of all FS blocks were completed, measured from the time pathologists received FS specimens to the time they communicated FS results to the surgeon.

RESULTS

Participants submitted data on 32868 FS blocks. Ninety percent of FS procedures were completed within 20 minutes. Frozen section turnaround times exceeding 20 minutes, termed outlier turnaround times, were more likely to occur when more than one pathologist participated in the FS diagnosis, pathology residents and medical students participated in the FS procedure, the pathologist had to retrieve and review previous case material during the FS procedure, the pathologist simultaneously received additional specimens from other FS cases, the pathologist was unable to reach a final FS diagnosis, and when technical problems occurred during the FS procedure. Seventy percent of all participating hospitals completed 90% of their frozen sections within 20 minutes. The institutional 90% completion times were shorter for hospitals containing 300 or fewer occupied beds than for those containing more than 300 occupied beds.

CONCLUSIONS

The data suggest that 90% of FS block turnaround times can be performed within 20 minutes, measured from the time that pathologists receive FS specimens to the time that pathologists return FS diagnoses to surgeons.

Fine needle aspiration of breast masses. An analysis of 1,398 patients in a community hospital

OBJECTIVE

To determine the diagnostic efficacy of breast fine needle aspiration (FNA) in the routine practice of a community hospital.

STUDY DESIGN

The study group consisted of 1,398 consecutive FNA biopsies of the female breast performed at our institution during a five-year period; 450 (32%) had histologic follow-up. Both FNA and the histologic diagnosis were compared in order to establish the accuracy, efficiency and safety of the FNA breast technique.

RESULTS

The sensitivity of the FNA procedure was 93.49% and specificity 95.73%, with a predictive value for a positive diagnosis of 93.49% and for a negative diagnosis, 95.73%. The overall diagnostic accuracy was 94.84%, and the sensitivity of cytologic diagnosis was 98.75%. The false negative and false positive rates were 2.5%, including 10 cases with suspicious diagnoses and only 1 false positive diagnosis (0.23%). The false positive and false negative cases were recorded as having no effect or a minimal effect on patient management, and no mastectomy was performed because of this FNA diagnosis.

CONCLUSION

FNA breast biopsy is an efficient tool for diagnosis when performed by surgical pathologists with cytologic training but not exclusively dedicated to cytopathology.

[Quality control of intraoperative diagnosis]

A retrospective study of 2500 consecutive frozen sections obtained in the period April 14, 1993, through April 29, 1995 from the Institute of Anatomic Pathology of Ospedale "Bellaria" of Bologna is presented. The most frequent of mistakes followed sampling errors. Quality Control of frozen section diagnoses is a valid system for monitoring and improving the accuracy of diagnoses.

Assessing the need for frozen sections: still a valuable tool in thyroid surgery

BACKGROUND

Since the development of fine-needle aspiration (FNA) there has been a trend away from frozen sections (FS) in the assessment of thyroid neoplasms. The objective of this study was to determine the role of FS in the surgical management of thyroid nodules in the presence of an adequate FNA biopsy finding.

METHODS

Charts of patients who presented within a 3-year period for thyroid surgery were reviewed. Inclusion criteria consisted of both an adequate FNA and FS.

RESULTS

Eighty-five patients met the inclusion criteria. Three lesions were benign, 71 were suspicious, and 11 were malignant with FNA. There were 66 deferred and 19 malignant diagnoses with FS. The overall accuracy for FNA and FS was 40% and 86%, respectively. When the FNA report was positive for malignancy, it was correct in 91% (10 of 11) of the cases. When the FNA report was suspicious, only 30% (21 of 71) had a malignant lesions. FS confirmed malignancy in 19 patients and deferred more extensive surgery in 66 patients with suspicious lesions. However, 18% of the deferred FS were found to be malignant on final pathology report.

CONCLUSIONS

This study showed that there is a role for FS in the surgical management of thyroid nodules. Frozen sections can be useful when the FNA report is suspicious for malignancy; however, FS may be eliminated when the FNA report is positive for malignancy.

Frozen section consultation. Utilization patterns and knowledge base of surgical faculty at a university hospital

The authors studied the knowledge base of surgical faculty concerning frozen section consultations at a university hospital to determine whether it had any relationship to the appropriateness of frozen section requests. To accomplish this, the reasons for performing frozen sections during a 3-month period were analyzed, and those request that seemed ambiguous or inappropriate were identified. Simultaneously a 15-item questionnaire was distributed to faculty and housestaff dealing with factual information concerning the technique and limitations of frozen section diagnosis (Questions 1-8), as well as appropriateness of frozen section requests in a number of clinical situations (Questions 9-15). The collective score on items of general information (Questions 1-8) was 69%, whereas scores on Questions 9-15 ranged from 39% on the gynecologic question related to evaluation of a cystic ovarian mass to 81% on the general surgery question regarding evaluation of a soft tissue mass. Of 914 frozen sections, 95% were performed for appropriate reasons, which included evaluation of margins (46%), establishing a primary diagnosis (43%), determining adequacy or viability of tissue (3%), or satisfying immediate patient/family concerns ( < 1%). Five percent of frozen sections were performed for ambiguous or seemingly inappropriate reasons. Because fewer than five faculty members were responsible for the inappropriate frozen section request, the authors did not find that the results of the questionnaire predicted or anticipated situations in which inappropriate requests occurred. Nonetheless, the results of the questionnaire indicate there is important general information concerning frozen sections that is not uniformly shared by surgical faculty, such as the types of tissue that cannot be cut on a cryostat, the reasons for deferred frozen sections, and the situations in which fresh tissue is needed for special studies. The authors suggest the inappropriate frozen section could be diminished by an educational initiative targeted at a relatively small segment of clinical faculty, whereas enhancement of general information regarding frozen section should ideally occur in the broader context of clinical conferences using illustrative case material.

Accuracy of fine needle aspiration in the pre-operative diagnosis of thyroid neoplasia

The aim of this study was to determine the accuracy and clinical utility of fine needle aspiration (FNA) for the preoperative diagnosis of patients presenting with solitary thyroid nodules. Between 1987 and 1991, 317 patients with a thyroid nodule underwent FNA. Surgery was performed on 98 of the patients, and the cytologic findings were correlated with the final histologic diagnoses for these cases. Of the 98 patients operated on, satisfactory aspirates were obtained in 85 patients and classified as either malignant, suspicious for malignancy, or benign. The FNA was correct in predicting malignancy in 29 of 35 nodules (82.9%). With the benign nodules, FNA was correct in 44 of 50 nodules (88%). The overall accuracy of FNA was 85.9%. The accuracy for the combination of FNA and frozen section (FS) was 92.6%. We conclude that both FNA and FS are accurate tests that play a useful role in the pre- and intraoperative diagnostic evaluation of patients presenting with solitary thyroid nodules.

[Quality control of intraoperative diagnosis. Annual review of 1490 frozen sections]

A retrospective evaluation of the accuracy of frozen section diagnoses over 1-year period has been carried out. Of 20998 surgical pathology specimens accessioned during 1991, 1265 (6.0%) had intraoperative pathologic consultation; 1490 were the frozen section examinations effectively carried out, with an average of 1.2 frozen section diagnoses per case. Of all frozen sections performed, 4.6% were deferred; in the remaining cases, the concordance between frozen sections and the final histologic diagnoses was 97%. The reasons for diagnostic discordances were gross sampling error (51.2%), misinterpretation (44.2%), microscopic sampling (9.3%), technical problems in sectioning (2.3%). We believe that a similar continuous monitoring should be performed in every pathology department, to recognize the reasons of errors and, if possible, to reduce them.

Diagnoses made by frozen-section examination of surgical specimens in a small Canadian hospital

Examination of frozen sections, which is frequently used to make diagnoses at the Plains Health Centre, Regina, is expensive in terms of manpower and resources of the pathology department and should be used judiciously. The authors analysed the pathology records from January to December 1990 and found that more than 10% of surgical specimens were submitted for frozen-section diagnosis. A correct diagnosis was made in 94.8% of cases, and in approximately 1% of cases the diagnosis was deferred until paraffin sections were examined. An incorrect diagnosis by frozen-section examination was made in 4.2% of cases. In 13.2% of cases, frozen-section examination was apparently performed for reasons that were not medically legitimate. In a further 14.9% of cases the value of frozen-section examination was questionable. Clinicians need to be educated about the correct role of frozen-section examination in patient management, especially in this era of restricted hospital budgets.