Intraoperative cytology when cryostat is not available. A 7-year experience in a Peruvian cancer center.

BACKGROUND: Intraoperative cytology (IC) is an alternative to frozen-section (FS) diagnosis. We present our experience with and the diagnostic value of IC during a 7-year period when FS was not available in a Peruvian Cancer Center. MATERIAL AND METHODS: This 7-year retrospective single-arm review study includes IC procedures performed by three pathologists between 2012 and 2018. These IC reports were reviewed independently by one pathologist and were correlated with the histologic diagnoses, which were used as the gold standard. All IC preparations (imprint, scrape, and crush smears) were stained with hematoxylin and eosin. IC interpretations were categorized as: malignant, benign, atypical, and "deferred to permanent sections." Sensitivity, specificity, and positive and negative predictive values were calculated by use of standard methods. RESULTS: A total of 1814 IC cases prepared from various organs obtained from 887 patients were reviewed. Malignant, benign, atypical, and "deferred to permanent sections" IC diagnoses were 26.3%, 68.9%, 3.7%, and 1.9%, respectively. Atypical and deferred cases were excluded from the statistical analysis; thus 1712 cases were found to be eligible. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall diagnostic accuracy were 91.6%, 97.7%, 94.1%, 96.7%, and 96%, respectively. CONCLUSION: In experienced hands, IC is a rapid, cost-effective, and accurate alternative diagnostic modality for intraoperative diagnosis when FS is not available.

Intraoperative frozen section performance for thyroid cancer diagnosis.

Objective: A primary medical relevance of thyroid nodules consists of excluding thyroid cancer, present in approximately 5% of all thyroid nodules. Fine-needle aspiration biopsy (FNAB) has a paramount role in distinguishing benign from malignant thyroid nodules due to its availability and diagnostic performance. Nevertheless, intraoperative frozen section (iFS) is still advocated as a valuable tool for surgery planning, especially for indeterminate nodules. Methods: To compare the FNAB and iFS performances in thyroid cancer diagnosis among nodules in Bethesda Categories (BC) I to VI. The performance of FNAB and iFS tests were calculated using final histopathology results as the gold standard. Results: In total, 316 patients were included in the analysis. Both FNAB and iFS data were available for 272 patients (86.1%). The overall malignancy rate was 30.4%% (n = 96). The FNAB sensitivity, specificity, and accuracy for benign (BC II) and malignant (BC V and VI) were 89.5%, 97.1%, and 94.1%, respectively. For all nodules evaluated, the iFS sensitivity, specificity, and accuracy were 80.9%, 100%, and 94.9%, respectively. For indeterminate nodules and follicular lesions (BC III and IV), the iFS sensitivity, specificity, and accuracy were 25%, 100%, and 88.7%, respectively. For BC I nodules, iFS had 95.2% of accuracy. Conclusion: Our results do not support routine iFS for indeterminate nodules or follicular neoplasms (BC III and IV) due to its low sensitivity. In these categories, iFS is not sufficiently accurate to guide the intraoperative management of thyroidectomies. iFS for BC I nodules could be an option and should be specifically investigated.

Intraoperative frozen section performance for thyroid cancer diagnosis

ABSTRACT Objective: A primary medical relevance of thyroid nodules consists of excluding thyroid cancer, present in approximately 5% of all thyroid nodules. Fine-needle aspiration biopsy (FNAB) has a paramount role in distinguishing benign from malignant thyroid nodules due to its availability and diagnostic performance. Nevertheless, intraoperative frozen section (iFS) is still advocated as a valuable tool for surgery planning, especially for indeterminate nodules. Subjects and methods: To compare the FNAB and iFS performances in thyroid cancer diagnosis among nodules in Bethesda Categories (BC) I to VI. The performance of FNAB and iFS tests were calculated using final histopathology results as the gold standard. Results: In total, 316 patients were included in the analysis. Both FNAB and iFS data were available for 272 patients (86.1%). The overall malignancy rate was 30.4%% (n = 96). The FNAB sensitivity, specificity, and accuracy for benign (BC II) and malignant (BC V and VI) were 89.5%, 97.1%, and 94.1%, respectively. For all nodules evaluated, the iFS sensitivity, specificity, and accuracy were 80.9%, 100%, and 94.9%, respectively. For indeterminate nodules and follicular lesions (BC III and IV), the iFS sensitivity, specificity, and accuracy were 25%, 100%, and 88.7%, respectively. For BC I nodules, iFS had 95.2% of accuracy. Conclusion: Our results do not support routine iFS for indeterminate nodules or follicular neoplasms (BC III and IV) due to its low sensitivity. In these categories, iFS is not sufficiently accurate to guide the intraoperative management of thyroidectomies. iFS for BC I nodules could be an option and should be specifically investigated

Is there a Role for Frozen Section Evaluation of Parotid Masses After Preoperative Cytology or Biopsy Diagnosis?

Fine-needle aspiration (FNA) biopsy reliably diagnoses parotid gland lesions preoperatively, whereas intraoperative frozen section (FS) has the additional benefit of assessing surgical margins and refining diagnoses; however, the role of FS in the setting of prior FNA diagnosis is not well established. Our aim was to determine whether FS should still be performed after a prior FNA/ CNB diagnosis. Parotid gland resections from January 2009 to January 2020 were identified; however, only patients who had both FNA and FS constituted our study population. For the purpose of statistical analysis, FNA diagnoses were classified into non-diagnostic (ND), non-neoplastic (NN), benign neoplasm (BN), indeterminate, and malignant. FS diagnoses were classified into benign, indeterminate, or malignant. Resections were dichotomized into benign and malignant and regarded as the gold standard to subsequently calculate diagnostic accuracy of FNA and FS. A total of 167 parotid gland resections were identified, but only 76 patients (45.5%) had both FNA and FS. In 35 cases deemed as benign preoperatively, three (8.6%) were reclassified as malignant on FS. Out of 18 lesions reported as malignant on FNA, four (22.2%) were interpreted as benign on FS, with three of these benign lesions confirmed on permanent slides. In addition, in patients with both FNA and FS, compared to FNA, FS was able to provide a definitive diagnosis in all five ND cases and in 61.1% (11/18) of indeterminate tumors. Intraoperative assessment provided a relative increase of 33.3% in specificity and 38.5% in positive predictive value when compared to preoperative FNA. The addition of FS to FNA was helpful to further refine the diagnoses of parotid gland lesions, which may provide better guidance for surgical intervention.

Systematic Review of the Use of Telepathology During Intraoperative Consultation.

OBJECTIVE: To compare studies that used telepathology systems vs conventional microscopy for intraoperative consultation (frozen-section) diagnosis. METHODS: A total of 56 telepathology studies with 13,996 cases in aggregate were identified through database searches. RESULTS: The concordance of telepathology with the reference standard was generally excellent, with a weighted mean of 96.9%. In comparison, we identified seven studies using conventional intraoperative consultation that showed a weighted mean concordance of 98.3%. Evaluation of the risk of bias showed that most of these studies were low risk. CONCLUSIONS: Despite limitations such as variation in reporting and publication bias, this systematic review provides strong support for the safety of using telepathology for intraoperative consultations.

Utility of Routine Frozen Section of Thyroid Nodules Classified as Follicular Neoplasm.

OBJECTIVES: To evaluate the diagnostic performance of frozen section in thyroid nodules classified as follicular neoplasm. METHODS: A diagnostic test meta-analysis was designed. Studies that assessed frozen section in patients with thyroid nodules and a fine-needle aspiration biopsy result of Bethesda IV were selected. The outcomes measured were the number of false- and true-positive and -negative results. We used the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) instrument for methodological quality assessment and a bivariate mixed-effects regression framework and a likelihood-based estimation of the exact binomial approach. RESULTS: Forty-six studies from 1991 to 2018 were included. Most studies had moderate methodological quality. The overall sensitivity and specificity were 43% (95% confidence internal [CI], 0.34-0.53) and 100% (95% CI, 0.99-1.00), respectively. The hierarchic summary receiver operating characteristic curve showed an area under the curve of 0.91 (95% CI, 0.80-0.97). CONCLUSIONS: Frozen section demonstrates moderate diagnostic performance in patients with follicular neoplasm, and its utility for making intraoperative decisions is limited. Its routine use should be discouraged.

Accuracy and interobserver agreement of retroareolar frozen sections in nipple-sparing mastectomies.

In the last decades, surgical treatment of breast cancer has enormously changed. As a result, nipple-sparing mastectomy (NSM) has evolved as an oncologically safe and cosmetic approach. NSM includes a subareolar frozen section to evaluate malignancy. We determined the accuracy of subareolar frozen section diagnosis, analyzed the discrepancy factor, and estimated the interobserver agreement of frozen section in NSM. A retrospective review of all NSMs at our institution from 2009 to 2015 was performed. Frozen sections were compared to the final diagnoses to analyze the accuracy of subareolar frozen sections. Discordant results were rigorously evaluated to identify discrepancy factors. Some cases were randomly chosen to assess the interobserver agreement (kappa) among pathologists. The agreement results were evaluated with and without knowledge of the tumor morphology. Among 34 NSMs, the frozen section false-negative and false-positive rate was 5.9% and 8.8%, respectively. The sensitivity and specificity was 77.8% and 88.0%, respectively. Sampling errors and diathermy artifacts explained our false-negative diagnoses. Freezing artifacts and an intraductal papilloma explained our false-positive diagnoses. The interobserver agreement between breast and general pathologists was 0.87 (p<0.0001) and 0.31 (p=0.0001), respectively. The interobserver agreement increased to 0.35 (p<0.0001) in general pathologists with knowledge of the tumor morphology. Subareolar frozen section showed to be a specific test with moderate sensitivity. Papillary lesions can mimic atypical cells and influence the frozen section interpretation. Frozen section in NSM had a better performance in breast pathologists (almost perfect) versus general pathologists (fair). Interobserver agreement may improve with knowledge of tumor morphology.

Validation of a new technique to freezing and embedding tissue in Mohs surgery, using an animal model.

PURPOSE: To validate the innovative Dry Ice method, comparing it with two standard methods currently used for tissue processing in Mohs surgery, the Heat Sink method and the Miami Special. METHODS: Forty eight samples of pigs kin with the standard beveled Mohs technique were used, and randomly allocated into six groups. Each group was processed with one of the 3 methods and evaluated for: The freezing time, the depth required to cut into the block to obtain a complete section, and the quality of histological slides analyzed with a image software. The statistical analysis was performed with the software SAS(r) System. The inferential analysis was made by one-way ANOVA. RESULTS: The Miami Special showed a processing time significantly shorter than Dry Ice method and Heat Sink method. There was no significant difference in the depth required to cut into the blocks, and area of surgical margins visualized. CONCLUSION: The Dry Ice method was as efficient as the other two methods currently used in Mohs surgery, considering the individual advantages and disadvantages of each method.

Validation of a new technique to freezing and embedding tissue in Mohs surgery, using an animal model

ABSTRACT PURPOSE: To validate the innovative Dry Ice method, comparing it with two standard methods currently used for tissue processing in Mohs surgery, the Heat Sink method and the Miami Special. METHODS: Forty eight samples of pigs kin with the standard beveled Mohs technique were used, and randomly allocated into six groups. Each group was processed with one of the 3 methods and evaluated for: The freezing time, the depth required to cut into the block to obtain a complete section, and the quality of histological slides analyzed with a image software. The statistical analysis was performed with the software SAS(r) System. The inferential analysis was made by one-way ANOVA. RESULTS: The Miami Special showed a processing time significantly shorter than Dry Ice method and Heat Sink method. There was no significant difference in the depth required to cut into the blocks, and area of surgical margins visualized. CONCLUSION: The Dry Ice method was as efficient as the other two methods currently used in Mohs surgery, considering the individual advantages and disadvantages of each method.

Sentinel lymph node biopsy in rats. Comparison between paraffin and frozen section analysis.

PURPOSE: To simulate a lymph node metastasis in an animal model using activated carbon, assess their identification in frozen section analysis and compare with histopathological examination in paraffin. METHODS: Thirty two adult female rats were used. They received the carbon injection on its hind legs. Half of the rats was sacrificed on day one, and the other half after 21 days. Thus, 64 lymph nodes were dissected and split longitudinally. One half of the lymph node was sent immediately to frozen section analysis. The other half was fixed in 10% formaldehyde to be cut in paraffin. Slides were divided into quadrants and classified by the presence of carbon in these four quadrants_ They were also classified by the carbon staining intensity. RESULTS: Comparing the slides obtained in the first day and 21 days, there was a tendency of carbon to spread over time, but without statistical significance. The intensity did not alter over time. CONCLUSION: There was no concordance between the two methods of pathological analysis, however the actived carbon was seen in all lymph nodes.

Sentinel lymph node biopsy in rats. Comparison between paraffin and frozen section analysis

PURPOSE: To simulate a lymph node metastasis in an animal model using activated carbon, assess their identification in frozen section analysis and compare with histopathological examination in paraffin. METHODS: Thirty two adult female rats were used. They received the carbon injection on its hind legs. Half of the rats was sacrificed on day one, and the other half after 21 days. Thus, 64 lymph nodes were dissected and split longitudinally. One half of the lymph node was sent immediately to frozen section analysis. The other half was fixed in 10% formaldehyde to be cut in paraffin. Slides were divided into quadrants and classified by the presence of carbon in these four quadrants_ They were also classified by the carbon staining intensity. RESULTS: Comparing the slides obtained in the first day and 21 days, there was a tendency of carbon to spread over time, but without statistical significance. The intensity did not alter over time. CONCLUSION: There was no concordance between the two methods of pathological analysis, however the actived carbon was seen in all lymph nodes. .

Acurácia da biópsia de congelação no câncer de pele não-melanoma / Accuracy of frozen section biopsy in non-melanoma skin cancer

Os carcinomas basocelular e espinocelular juntos respondem por mais da metade dos casos novos de câncer. A biópsia de congelação é frequentemente usada em áreas como cabeça e pescoço, nas quais uma margem ampla poderia ocasionar cicatrizes desfigurantes ou dificuldades de reconstrução, porém o resultado da biópsia de congelação nem sempre corresponde ao da parafina. O presente trabalho tem como objetivo fazer uma revisão bibliográfica sobre a correlação do resultado da biópsia de congelação intraoperatória e o resultado final do exame anatomopatológico da peça cirúrgica (exame de parafina), pela sua importância na ressecção curativa e na reconstrução do local acometido. Foi realizado levantamento bibliográfico, tendo como base artigos científicos publicados a respeito da acurácia da biópsia de congelação nos últimos 10 anos. A biópsia de congelação é um método eficiente e confiável, que deve ser aplicado em áreas em que a ressecção deve ser a mais econômica possível. Em áreas com tumor pequeno e sobra de pele a biópsia de congelação é pobre, dispensável e não altera resultados. A biópsia de congelação se mostrou um método eficiente, de custo acessível e de boa reprodutibilidade quando realizada por profissionais experientes e em casos bem indicados.

Together, basal cell and squamous carcinomas account for more than 50% of all new cases of cancer. Frozen section biopsy is often used in areas such as the head and neck, in which a wide margin could cause disfiguring scars or difficulties with reconstruction, but the results of frozen biopsy do not always correspond to the results of paraffin sections. This paper aims to review existing literature on the correlation between the results of intraoperative frozen biopsy and final pathological examination of surgical specimens (examination of paraffin sections), because of the importance of frozen biopsy in curative resection and reconstruction of affected sites. A literature review was conducted, based on scientific articles published over the previous 10 years about the accuracy of intraoperative frozen sections. Frozen section biopsy is an efficient and reliable method that should be applied in areas where resection should be as economical as possible. However, in cases with small tumors and excess skin, the results of frozen biopsy are poor, dispensable, and not meaningful. Frozen biopsy is an efficient, affordable, and reproducible method when performed by experienced staff in well-selected cases.

Proporción de tenascina y fibronectina en el ligamento periodontal de dientes sometidos a fuerzas ortodónticas / Tenascin and fibronectin proportions in human periodontal ligament of teeth undergoing orthodontic forces

El presente estudio tuvo como objetivo comprobar los cambios en la proporción de tenascina (T) y fibronectina (F) en la zona de tensión del ligamento periodontal humano (LPH) de dientes sometidos a fuerzas ortodónticas. Se tomaron muestras de LPH en 20 pacientes entre 18 y 25 años. A los dientes del grupo experimental se les aplicó una fuerza con intervalos de 1, 21 y 40 días. Las muestras fueron congeladas en nitrógeno líquido y posteriormente sometidas a tinción inmunohistoquímica. Para el grupo de F, el primer día se observó que los dientes del grupo control presentaban una tinción leve. En el grupo experimental se observó que las siete muestras presentaban una tinción leve. En el día 21, cinco de las siete muestras presentaban una tinción moderada y las dos restantes, una tinción intensa. En el día 40, en todas se observó una tinción intensa. En el grupo control de T, las muestras presentaron una tinción leve. En el primer día se observó una tinción moderada. En el día 21, cuatro presentaron una tinción intensa y las tres restantes, una tinción moderada. En el día 40 fue leve. Los resultados sugieren la posible relación de la F y la T en los procesos de neoformación en la zona de tensión, contribuyendo a la mejor comprensión de los procesos moleculares involucrados al aplicar fuerzas ortodónticas en los dientes

Papel da congelaçäo e da citopatologia no diagnóstico das neoplasias da tireóide / Freenzing and cytopathology rule in the diagnosis of thyroid neoplasm

A punçäo aspirativa com agulha fina (PAAF) é o método ideal para detecçäo de malignidade em nódulos de tireóide e tem sido sugerida como uma alternativa à congelaçäo para guiar a conduta cirúrgica. Este estudo avaliou ambos os métodos no diagnóstico das neoplasias da tireóide num hospital geral de ensino onde a PAAF é realizado por médicos em treinamento. A PAAF foi realizada pelo método de Soderstrom e a congelaçäo pelo método de MacCarty. O exame histopatológico definitivo foi utilizado como critério padräo de diagnóstico. Trezentas e quarenta e duas tireoidectomias foram analisadas. Havia 77 casos de cancer e 42 adenomas confirmados como positivos pela histopatologia. Em 199 PAAF com material adequado, 45,2 por cento (90/199) dos casos mostravam resultados citopatológicos sugestivos de neoplasia, com evidências citopatológicas de neoplasia maligna ou com atipias e considerados positivos, mas a sensibilidade foi de 68,7 por cento (57/83); 36,6 por cento (33/90) destes casos näo foram confirmados, configurando uma especificidade de 71,6 por cento (83/116). Em 263 congelaçöes, 76,4 por cento dos diagnósticos sugeriam uma natureza benigna (79,1 por cento) ou maligna (20,9 por cento) para lesao nodular. Todas as congelaçöes sugestivas de cancer foram confirmadas. Houve 23,6 por cento dos casos definidos como neoplasia folicular circunscrita, cuja malignidade foi definida após estudo de vários cortes histológicos; destes, 16,1 por cento eram carcinomas e 41,9 por cento eram adenomas, configurando uma especificidade 85,1 por cento (154/181). Houve dois casos de adenoma e tres casos de carcinoma näo identificados pela congelaçäo, configurando uma sensibilidade de 93,9 por cento (77/82). Em 157 casos onde foram realizados PAAF e congelaçäo concomitantemente, os níveis de sensibilidade e especificidade foram, respectivamente, 63,8 vs 98,3 por cento e 73,7 vs 79,8 por cento. Estes dados sugerem que a PAAF realizada por médicos em treinamento ainda nao dispensa a realizaçäo da congelaçäo como um guia para a conduta cirúrgica, visto que ainda apresenta uma menor sensibilidade.

¿Es de utilidad la biopsia rapida en el diagnóstico de las lesiones foliculares de tiroides? / Utility of rapid biopsy in follicular thyroid neoplasms

Se analizan las ventajas y desventajas de la biopsia por congelación (contemporánea) en el diagnóstico intraoperatorio de los nódulos tiroides y se comentan los problemas que se plantean en el diagnóstico de malignidad en las lesioens de patrón folicular. Estas lesiones son responsables del bajo rendimiento de esta técnica, lo cual está objetivamente evidenciado por el alto porcentaje de biopsias que son diferidas para su posterior análisis en cortes permanentes, los cuales permiten lograr el diagnóstico definitivo

Biopsia contemporánea: evaluación retrospectiva de 326 casos / Contemporary biosy: retrospective evaluation of 326 cases

En 326 biopsias contemporáneas consecutivas realizadas durante 1989 y 1990 en el Servicio de Anatomía Patológica del Hospital John F. Kennedy de Valdivia, se consigna su distribución por órganos; se evalúa la certeza diagnóstica que alcanza al 91.7 por ciento y se compara con publicaciones previas