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Frozen section (intraoperative consultation)
Human PATHOLOGY VOLUME 19
September 1988
NUMBER 9
Editorial
Frozen Section [Intraoperative Consultation] Studies of significant numbers of cases assessing the accuracy of frozen section (FS) diagnosis began appearing in the literature in the 1950s. Since the application of the cryostat to FS diagnosis was documented in 1959, many additional reports have been published, including several recent ones cited by Sawady et al in their article, "Accuracy of and Reasons for Frozen Sections," which appears in this issue of the Journal. Against this background, one might wonder why another study dealing with the accuracy of FS should be published. The answer lies in the operative word "Reasons" in the title of their report. The authors squarely address the fact that markedly different questions are asked of the pathologist at the time of FS. They document classes of FS that have a high rate of diagnostic accuracy and define a class that is at a greater risk for diagnostic error or no diagnosis at all. The latter group may be called the "What is it?" class. When discussing accuracy of diagnosis, the distinction between classes becomes important. The accuracy rates of FS diagnosis reported in the literature usually range from 94% to 98%. Such studies have always come from large institutions where there are high volumes of FS. Large referral hospitals may favor a class of FS diagnoses; namely, the assessment of margins when major cancer surgery is performed and the diagnosis of malignancy has been previously establisb,zd. It also seems reasonable (although I have no supportive data) that there will be a higher accuracy rate in large hospitals because of more experience and, perhaps, a greater number of immediately available consultants. On the other hand, the pathologist in a smaller hospital may encounter more undiagnosed cases in the "What is it?" category; therefore, he or she should not be apologetic or feel professionally substandard for an accuracy rate of less than 90%. This is especially important if FS accuracy is to be included in the burgeoning emphasis on quality assurance. The recognition of different classes of FS, as outlined by Sawady et al, must be considered.
Requests for FS are occasionally unreasonable because of the lack of knowledge regarding the technical and professional interpretive methodology and limitations of the technique. For example, requesting an FS on a small breast biopsy lacking any gross evidence of invasive carcinoma is compromising the care of the patient. Situations such as this provide an opportunity for educating the surgeon regarding problems that are inherent in FS. T h e pathologist must explain that the interpretation of non-invasive breast lesions on FS is diagnostically hazardous because of the possible suboptimal nature o f the section, and that the FS artifact in the s u b s e q u e n t paraffinembedded tissue section from the frozen block may also render it inconclusive. Having spent approximately half of my professional life in a private hospital and the other half in a university hospital, I have not detected any difference in the quality or quantity of unreasonable requests. This undoubtedly reflects a prevailing lack of sufficient exposure (or no exposure) to pathology in surgical residency programs. Most surgeons have never gained any familiarity with the technical aspects of the pathologists' work, much less any insight into the mental processes that result in the formulation of a diagnosis. However, unreasonable requests can be decreased by gradually educating practicing surgeons on the intricacies of our specialty. This may require considerable restraint and patience, but I believe it is a high-priority educational obligation. We must thoughtfully, carefully, and repeatedly explain our role as the individuals who are most knowledgeable in the proper handling of tissue for the maximum benefit of the patient. Making a diagnostic error on FS, even if causing no harm to the patient, is especially annoying when the FS is requested out of curiosity and not because it will alter the immediate management of the patient. As an aside, whether or not the pathologist will be financially compensated for the "curiosity FS" may become an important issue in the future. ! agree with those who have suggested that pa999
HUMAN PATHOLOGY
Volume 19, No, 9 [September 1988]
thologists should think of FS as an "intraoperative consultation" and use this term instead of FS. As previously mentioned, some intraoperative consultations do not culminate in FS. The intraoperative decision not to perform an FS is fully as critical as rendering a diagnosis on an FS slide. The term "intraoperative consultation" also seems preferable because it encompasses other diagnostic techniques, such as gross diagnosis, touch imprints, and intraoperative fine needle aspiration. Finally, the importance of communication between the surgeon and pathologist can never be overemphasized. T h e surgeon who thinks he or she is testing the pathologist's diagnostic ability by with-
holding relevant information is acting in an irresponsible, unprofessional manner and playing a dangerous game, with the patient's well-being at stake. No less irresponsible is the pathologist who is reticent to ask for additional clinical information out of fear that this will reflect poorly on his or her diagnostic acumen. An atmosphere of open communication and mutual trust must be nurtured between surgeons and pathologists to ensure that the patient receives the benefit of the best possible pathologic diagnosis. Robert E. Fechner, MD Charlottesville, VA
1000
September 1988
NUMBER 9
Editorial
Frozen Section [Intraoperative Consultation] Studies of significant numbers of cases assessing the accuracy of frozen section (FS) diagnosis began appearing in the literature in the 1950s. Since the application of the cryostat to FS diagnosis was documented in 1959, many additional reports have been published, including several recent ones cited by Sawady et al in their article, "Accuracy of and Reasons for Frozen Sections," which appears in this issue of the Journal. Against this background, one might wonder why another study dealing with the accuracy of FS should be published. The answer lies in the operative word "Reasons" in the title of their report. The authors squarely address the fact that markedly different questions are asked of the pathologist at the time of FS. They document classes of FS that have a high rate of diagnostic accuracy and define a class that is at a greater risk for diagnostic error or no diagnosis at all. The latter group may be called the "What is it?" class. When discussing accuracy of diagnosis, the distinction between classes becomes important. The accuracy rates of FS diagnosis reported in the literature usually range from 94% to 98%. Such studies have always come from large institutions where there are high volumes of FS. Large referral hospitals may favor a class of FS diagnoses; namely, the assessment of margins when major cancer surgery is performed and the diagnosis of malignancy has been previously establisb,zd. It also seems reasonable (although I have no supportive data) that there will be a higher accuracy rate in large hospitals because of more experience and, perhaps, a greater number of immediately available consultants. On the other hand, the pathologist in a smaller hospital may encounter more undiagnosed cases in the "What is it?" category; therefore, he or she should not be apologetic or feel professionally substandard for an accuracy rate of less than 90%. This is especially important if FS accuracy is to be included in the burgeoning emphasis on quality assurance. The recognition of different classes of FS, as outlined by Sawady et al, must be considered.
Requests for FS are occasionally unreasonable because of the lack of knowledge regarding the technical and professional interpretive methodology and limitations of the technique. For example, requesting an FS on a small breast biopsy lacking any gross evidence of invasive carcinoma is compromising the care of the patient. Situations such as this provide an opportunity for educating the surgeon regarding problems that are inherent in FS. T h e pathologist must explain that the interpretation of non-invasive breast lesions on FS is diagnostically hazardous because of the possible suboptimal nature o f the section, and that the FS artifact in the s u b s e q u e n t paraffinembedded tissue section from the frozen block may also render it inconclusive. Having spent approximately half of my professional life in a private hospital and the other half in a university hospital, I have not detected any difference in the quality or quantity of unreasonable requests. This undoubtedly reflects a prevailing lack of sufficient exposure (or no exposure) to pathology in surgical residency programs. Most surgeons have never gained any familiarity with the technical aspects of the pathologists' work, much less any insight into the mental processes that result in the formulation of a diagnosis. However, unreasonable requests can be decreased by gradually educating practicing surgeons on the intricacies of our specialty. This may require considerable restraint and patience, but I believe it is a high-priority educational obligation. We must thoughtfully, carefully, and repeatedly explain our role as the individuals who are most knowledgeable in the proper handling of tissue for the maximum benefit of the patient. Making a diagnostic error on FS, even if causing no harm to the patient, is especially annoying when the FS is requested out of curiosity and not because it will alter the immediate management of the patient. As an aside, whether or not the pathologist will be financially compensated for the "curiosity FS" may become an important issue in the future. ! agree with those who have suggested that pa999
HUMAN PATHOLOGY
Volume 19, No, 9 [September 1988]
thologists should think of FS as an "intraoperative consultation" and use this term instead of FS. As previously mentioned, some intraoperative consultations do not culminate in FS. The intraoperative decision not to perform an FS is fully as critical as rendering a diagnosis on an FS slide. The term "intraoperative consultation" also seems preferable because it encompasses other diagnostic techniques, such as gross diagnosis, touch imprints, and intraoperative fine needle aspiration. Finally, the importance of communication between the surgeon and pathologist can never be overemphasized. T h e surgeon who thinks he or she is testing the pathologist's diagnostic ability by with-
holding relevant information is acting in an irresponsible, unprofessional manner and playing a dangerous game, with the patient's well-being at stake. No less irresponsible is the pathologist who is reticent to ask for additional clinical information out of fear that this will reflect poorly on his or her diagnostic acumen. An atmosphere of open communication and mutual trust must be nurtured between surgeons and pathologists to ensure that the patient receives the benefit of the best possible pathologic diagnosis. Robert E. Fechner, MD Charlottesville, VA
1000