Ridiculous FS

[MadSci]

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Frozen sections: (FS)

label --- actual

sentinel node---axilary node dx
pus -- pus
breast cancer -- mastectomy
lung resection --- FS on tumor



jeez..

 

[yaah]

Yeah, I love when they send those sentinel nodes down for frozen. You figure, well, if it's positive I guess they are going to do the node dissection. But no, they are going to do it later if it is positive, the same as if it was sent for permanent. They just want to tell the patient.

You really had a frozen on a mastectomy? That's sad.

We had one on a POC the other night - they did a D&C for a probably missed AB and the tissue they sent had only decidua. So we called in, but they had already left the OR and the patient was waking up (I think they brought the patient and the specimen out of the room at the same time). We said there were no villi and they said fine. We asked if there was anything else or whether that was everything, and out of curiosity, what were they going to do clinically now? The response: Oh, here is the rest of the tissue for permanent section, we'll wait for the results on that. We did an ultrasound pre-op and there was no evidence of an ectopic.

🙄

Another good one was a patient having a large mediastinal mass (thymic carcinoid) resected. They send a lung wedge with a nodule for frozen (rule out cancer mets). It was an abscess. They said, "No it isn't, it's metastatic disease." Surg path fellow said they should send some intraop cultures because it was not cancer. 20 minutes later they sent a second lung wedge for frozen with a nodule. Rule out cancer. Results: Abscess, recommend culture. They didn't believe it even then. 5 days later we get a page from the ID team because the patient clearly has pneumonia but they can't culture anything on sputum, and want bug stains on the tissue. They never did send any tissue for culture. 🙄

 

[AngryTesticle]

Yeah, I love when they send those sentinel nodes down for frozen. You figure, well, if it's positive I guess they are going to do the node dissection. But no, they are going to do it later if it is positive, the same as if it was sent for permanent. They just want to tell the patient.

Really? Here, we get almost all the sentinel nodes for frozen and if the node is positive, two things happen: (1) tumor banking comes in to do their thing (2) axillary node dissection takes place. In your situation, I think it's kinda ridiculous that sentinel frozen sections don't impact intraoperative management. If they're gonna do it later, they should defer the sentinel node for permanents. Many sentinel nodes are very fatty and hard to cut and you end up wasting some tissue which could be bad since you could conceivably miss a small micrometastatic focus of tumor.

Another good one was a patient having a large mediastinal mass (thymic carcinoid) resected. They send a lung wedge with a nodule for frozen (rule out cancer mets). It was an abscess. They said, "No it isn't, it's metastatic disease." Surg path fellow said they should send some intraop cultures because it was not cancer. 20 minutes later they sent a second lung wedge for frozen with a nodule. Rule out cancer. Results: Abscess, recommend culture. They didn't believe it even then. 5 days later we get a page from the ID team because the patient clearly has pneumonia but they can't culture anything on sputum, and want bug stains on the tissue. They never did send any tissue for culture. 🙄

Ai ya! Or even better yet...you end up getting granulomatous mass instead of tumor and so you're thinking maybe possibly the patient has TB. Then you're thinking, "oh crap! i might have been exposed." This is especially bad if the notes in the patient's record aren't very extensive and you're not absolutely certain that TB has not been ruled out in the patient.

 

[yaah]

Ai ya! Or even better yet...you end up getting granulomatous mass instead of tumor and so you're thinking maybe possibly the patient has TB. Then you're thinking, "oh crap! i might have been exposed." This is especially bad if the notes in the patient's record aren't very extensive and you're not absolutely certain that TB has not been ruled out in the patient.

Interestingly, the cryostat was contaminated one day last week because they did a frozen on a lung wedge which turned out to be necrotizing granulomatous inflammation. So one cryostat had to be decontaminated. Then an hour later a surgeon requested a frozen to rule out TB on a spinal mass or something like that. They asked him how it was going to change his procedure, and he said it wasn't, that he needed to know. So they offered him rush processing because if it was positive, frozen sections would basically be shut down for the day. He still wouldn't budge until a couple of path attendings got involved.

 

[DermpathDO]

Really? Here, we get almost all the sentinel nodes for frozen and if the node is positive, two things happen: (1) tumor banking comes in to do their thing (2) axillary node dissection takes place. In your situation, I think it's kinda ridiculous that sentinel frozen sections don't impact intraoperative management. If they're gonna do it later, they should defer the sentinel node for permanents. Many sentinel nodes are very fatty and hard to cut and you end up wasting some tissue which could be bad since you could conceivably miss a small micrometastatic focus of tumor.


Ai ya! Or even better yet...you end up getting granulomatous mass instead of tumor and so you're thinking maybe possibly the patient has TB. Then you're thinking, "oh crap! i might have been exposed." This is especially bad if the notes in the patient's record aren't very extensive and you're not absolutely certain that TB has not been ruled out in the patient.

Yep,
Happened to us a couple of times. Seems we have seroconverted because of that and now have postive TB tests because our surgeons/pulmonary docs can't seem to do some decent screening on thier patient's BEFORE they start operating on them!

 

[DermpathDO]

Interestingly, the cryostat was contaminated one day last week because they did a frozen on a lung wedge which turned out to be necrotizing granulomatous inflammation. So one cryostat had to be decontaminated. Then an hour later a surgeon requested a frozen to rule out TB on a spinal mass or something like that. They asked him how it was going to change his procedure, and he said it wasn't, that he needed to know. So they offered him rush processing because if it was positive, frozen sections would basically be shut down for the day. He still wouldn't budge until a couple of path attendings got involved.

As for this one?? well it don't get any better in the real world! In one of our divisions( each of the 3 has 2 crytostats) both cryostats were contaminated simultaneously by a thoracic surgeon who wanted frozens on two masses from the mediastinum and upper right lobe. Both were necrotizing granulomas( HELLO!! GHON"S COMPLEX ANY ONE???). perms showed masses of AFB. Later that day another surgeon pissed because he couldn't get a frozen due to decontamination procedures on those cryostats( we had to ship the tissue to one of the other divisions and it took an additional half hour)...we told him...go talk to the surgeon who did the frozens this am and contaminated them. Never heard if he did... 🙄

 

[yaah]

It is odd - we had a frozen once on a lung wedge on a patient with unknown interstitial disease. They weren't trying to rule out tumor, just get a diagnosis. So they sent the lung wedge for frozen.

There are also certain cases where some surgeons ALWAYS have to send a frozen. Like some surgeons with ovarian cysts - even if radiology says it's a dermoid (and when radiology is confident enough to actually call it something and not hedge, you know it's probably a pretty safe bet that's what it is). I got called in at 2:30 am on thursday AM because the surgeon was about to start a case for an ovarian cyst - "We definitely need a frozen, it might be cancer!" Now, one question is WHY do you still need a frozen? It's 3am, you are not going to call the gyn-onc people in to do a full TAH-BSO with staging in a 25 year old woman where radiology and labs are not suspicious for cancer, even if the frozen suggests it. You would go back and restage later. Turns out he decided he didn't need the frozen. That's ok, I didn't have anything to do anyway. 🙄 And then surgeons complain when we balk at coming in before they are actually ready for the frozen since half the time they cancel it anyway.