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made with the document.
See also: Frozen section policies:
25, 26,
27, 41,
86.
PRINCIPLE OF THE TEST.
Frozen sections are special consultations, provided by pathologists
for intraoperative guidance.
SPECIMEN REQUIRED.
All fresh human tissue excised at surgery, along with a filled-out
Tissue Examination Form
(U. S. Standard Form 515, USSF515), with a request
for frozen section on the form, and personally handed
to a histology technician, a resident, or an attending pathologist,
The specimen may be frozen or occasionally examined grossly only,
and submitted for permanent (see #9).
REAGENTS, INSTRUMENTATION.
OCT Compound. Cryostat.
Frozen section solutions for hematoxylin and eosin staining.
STEP-BY-STEP DESCRIPTION.
1. Frozen sections are special consultations,
provided by pathologists to provide intraoperative guidance to surgeons.
Because cryostat sections are inferior to permanent sections,
frozen section diagnoses are not considered the final diagnosis
for a specimen.
2. In the best of departments, there will be
an irreducible number of instances where the report given
for the frozen section will turn out to be incorrect when reviewed
on the permanent section. Published values for such discrepancies
are up to 5%. We perform frozen sections with the understanding
that the surgeon, aware of these inherent limitations,
wants our best judgment in order to make a necessary
intraoperative clinical decision.
3. The histology laboratory, Room 4D-124, is the normal place
of delivery for all surgical specimens during working hours,
8:00 AM through 4:30 PM.
Before a frozen section is submitted, the histology laboratory (ext 5359)
should be notified, by telephone or intercom, that a specimen
will be arriving at a specified, estimated time.
4. All specimens requiring urgent attention should be
personally handed to a histology technician, a resident,
or an attending pathologist, with the statement that
this is an urgent, intraoperative consultation.
If an operation started during the day is likely to require frozen sections
after 4:30 PM, then the on-call anatomic pathologist should be notified
before 4:30 PM.
5. An anatomic pathologist is on-call at all times,
and the on-call schedule
is posted monthly with the paging operator. After hours, the
on-call pathologist should be notified at least an hour before
the frozen section will arrive in pathology, if at all possible.
6. All these procedures are discussed in this on-line
Surgical Pathology Manual for the Pathology and Laboratory Medicine
Service (Procedures
24,
25)
which can be viewed by all staff persons
on the Baltimore-VAMHCS intranet at URL:
http://vaww.vamhcs.med.va.gov
Click on DEPARTMENTS AND SERVICES.
Click on PATHOLOGY AND LABORATORY SERVICE.
Click on SURGICAL PATHOLOGY AND CYTOPATHOLOGY.
Click on TABLE OF CONTENTS.
7. The frozen section should be submitted fresh
in a properly identified container, along with the carbon copy
of the SF-515 form that will eventually accompany the final specimen.
In most cases, this SF-515 form will be computer-generated
in the operating room.
8. Instructions to the pathologist (often in the form of
a diagram orienting the pathologist to the specimen) should be clear.
The pathologist reviews the request, and decides whether a frozen section
should be performed. In most instances, the pathologist complies
with the request of the surgeon.
9. In a small percentage of cases, the pathologist
may wish to question the type of frozen section requested ,
or even the need to perform a frozen section.
The pathologist will always call the Operating Room
to discuss frozen sections when there is some problem
in complying with the consultation request.
Operating Room personnel must be aware that
circumstances may limit the ability of the pathologist
to comply with a particular frozen section request.
In the appropriate clinicopathologic circumstances,
the specimen may be examined grossly only
and submitted for permanent section.
These circumstances include, but are not limited to:
margins on a pigmented skin lesion or an ovarian cyst.
The surgeon should be prepared to discuss these
problems with the pathologist when they arise.
10. As the patient chart does not accompany
the frozen section request, the pathologist relies
heavily upon the clinical information supplied on the frozen section
submission form for guidance. However, because potentially
infectious cases may arrive as frozen section submissions
without any biohazard warning and without any mention
in the clinical history contained on the submission sheet,
the pathologist may elect to check on the patient's infectious status,
searching the VistA® computer system for the results of HIV,
hepatitis, or any other test deemed relevant by the pathologist.
Further, the pathologist may elect to read the clinical notes
provided in the VISTA computer system.
The pathologist may elect to pursue this type of review prior to
processing the tissue, especially if the pathologist determines
that the results of the review may abort the frozen section or provide
information that directs the pathologist to pursue alternate forms of
intraoperative consultation (particularly smear diagnosis).
11. It is important for optimal patient care to provide a frozen
section diagnosis in a timely manner. The pathology department can usually
provide a frozen section diagnosis for each tissue-block within
20 minutes of receipt of the specimen. The time required to deliver the
specimen to us from the Operating Room is not under control of the surgical
pathology section, and can add appreciably to the overall response time
on a frozen section. The pathologist notifies the Operating Room by intercom
of the diagnosis as soon as possible after it is rendered. To assist
in expeditious processing of large or complicated specimens, the surgeon
should orient the specimen with ink or sutures, and either accompany
the specimen to the pathology area, or provide written orientation
information on the Tissue Examination Form. In cases where the specimen
exceeds 1 cm, representative areas-of-interest should be indicated;
otherwise, the diagnosis may be delayed. Surgeons are always welcome
to join the pathologist at the microscope in the anatomic pathology
signout room, 4D-139, for additional consultation.
12. The pathologist will first confirm that he has contacted
the appropriate Operating Room, by stating the patient's name and
full social security number. After the pathologist reads the patient's name,
full social security number, and diagnosis,
the surgeon should acknowledge that he has heard the diagnosis.
The surgeon's acknowledgment is recorded on the Tissue Examination
Form by the pathologist, by stating: DIAGNOSIS xxx READ TO
DR. xxx IN O.R. xxx AT DATE/TIME, AND READ BACK. The frozen section
report, including a statement of the surgeon's acknowledgment,
is included as an addendum to the Gross Description
section of the surgical pathology report, and becomes part of the
patient's permanent medical record.
13. FROZEN SECTION TURNAROUND TIME PILOT STUDY.
A Frozen Section Turnaround time pilot study was performed for the period
March 1, 2001, through December 31, 2001. During this time, there were 360
frozen section reports recorded in the frozen section. In the same period,
there were 4,134 cases from year 2000 and 4,920 cases from year 2001.
Thus, frozen section reports were issued for 4% of cases. For a single case
(0.3%), the report was available only after 22 minutes of receiving tissue
from the operating room.
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