The role of intra-operative pathological evaluation in the management of musculoskeletal tumours

The Accuracy and Clinical Utility of Intraoperative Frozen Section Analysis in Open Biopsy of Bone

BACKGROUND

Open biopsy of bone is the diagnostic benchmark for the diagnosis of skeletal lesions. Intraoperative pathology consultation with frozen section analysis is commonly performed to confirm adequacy of lesional tissue and guide intraoperative decision making. The purpose of this study was to determine the accuracy and clinical utility of intraoperative frozen section during open bone biopsy.

METHODS

A retrospective review of 485 open biopsies of osseous lesions from 474 patients between 1997 and 2014 was performed. Pathology reports, operative notes, and prebiopsy imaging were assessed to determine the accuracy rates of frozen section analysis compared with final pathology. Pearson chi-squared and Fisher exact tests were performed to compare the accuracy and clinical utility rates based on soft-tissue extension, previous biopsy, lesional consistency, disease, and location.

RESULTS

Overall diagnostic yield of open bone biopsy was 95.3%. Frozen section analysis was accurate in 54.2%, equivocal positive in 21.2%, equivocal negative in 21.0%, and incorrect in 3.5% of cases. Previous nondiagnostic biopsy and the type of disease were found to have statistically significant effects on the accuracy of frozen section analysis.

CONCLUSION

Frozen section analysis was diagnostic in approximately one half of open biopsy cases. Additional information in equivocal positive results suggests that frozen section analysis is helpful for intraoperative decision making (clinical utility) in 75.4% of cases.

LEVEL OF EVIDENCE

Retrospective review level IV.

[Frozen section diagnostics in osteopathology]

Bone tumors are very rare and this is the reason why frozen section diagnosis is often difficult. The orthopedic surgeon wants to know the intraoperative diagnosis of biopsies of benign or malignant bone tumors so that definitive treatment can be carried out immediately in cases of diagnostic certainty. Diagnostic problems not only concern the distinction of benign and malignant tumors but also differentiation of a neoplastic from a reactive process. Clinical information is very important and all patients with bone tumors are discussed before surgical treatment in an interdisciplinary tumor board. Internationally but with the exception of the USA, the diagnostic procedure using frozen sections is not commonly used even in specialized centers.

[The use of frozen sections in the handling of soft tissue tumors]

Due to the multiplicity of localizations and entities, handling of soft tissue tumors is a very challenging subject requiring intensive interdisciplinary collaboration. With respect to the use of intraoperative frozen sections, the following facts are of special relevance: 1) the usual criteria for malignancy, such as infiltrative growth and high mitotic rate are only restrictedly applicable to soft tissue tumors. 2) Correct diagnosis of the tumor entity often requires not only the use of immunohistochemistry but also the identification of genetic alterations by the polymerase chain reaction and/or fluorescence in situ hybridization. In many centres, 14G core biopsies taken from different tumor areas represent the preferred method for a diagnostic biopsy. Apart from cryocollection additional frozen section investigations are used especially in case of open biopsies for quality control of the submitted material or in cases of excision biopsies to ascertain a highly probable radiological diagnosis. The use of intraoperative frozen sections to clarify the resection margins is generally undisputed but should definitely be restricted to centres specialized and experienced in the handling of soft tissue tumors.

[Frozen section diagnostics in osteopathology]

Bone tumors are very rare and this is the reason why frozen section diagnosis is often difficult. The orthopedic surgeon wants to know the intraoperative diagnosis of biopsies of benign or malignant bone tumors so that definitive treatment can be carried out immediately in cases of diagnostic certainty. Diagnostic problems not only concern the distinction of benign and malignant tumors but also differentiation of a neoplastic from a reactive process. Clinical information is very important and all patients with bone tumors are discussed before surgical treatment in an interdisciplinary tumor board. Internationally but with the exception of the USA, the diagnostic procedure using frozen sections is not commonly used even in specialized centers.

Implementation of molecular phenotyping approaches in the personalized surgical patient journey

OBJECTIVE

The present review describes commonly employed metabolic profiling platforms and discusses the current and likely future application of these technologies in surgery.

BACKGROUND

The metabolic adaptations that occur in response to surgical illness and trauma are incompletely understood. Evaluating these will be critical to the development of personalized surgical health solutions. Metabonomics is an advancing field in systems biology, which provides a means of interrogating these metabolic shifts.

METHODS

Recent literature regarding metabolic profiling technologies and their applications in surgical practice are discussed. Future strategies are proposed for the incorporation of these and next-generation technologies in the evaluation of all steps in the patient surgical pathway.

RESULTS

Metabolite-based profiling has provided valuable insights into the metabolic irregularities that occur in cancer development and progression across a variety of cancer subclasses including colorectal, breast, prostate, and lung cancers. In addition, metabolic modeling has shown considerable promise in other surgical conditions including trauma and sepsis and in the assessment of pharmacotherapeutic efficacy.

DISCUSSION

Metabonomics offers a posttranscriptional view of system activity providing functional information downstream of the genome and proteome. Information at this level will provide the surgeon with a novel means of evaluating major socioeconomic problems such as cancer and sepsis. In addition, the rapid nature of emerging next generation profiling platforms provides a viable means of "real-time" perioperative metabolic assessment and optimization.

Coccidioides, cryptococcus, or blastomyces? A diagnostic dilemma encountered during frozen section evaluation

Intraoperative consultation via frozen section is an important part of modern day surgical pathology. Recognizing fungi in tissues on frozen and permanent sections is not always a simple task, and correctly identifying the agent can be a significant challenge, even for experienced microscopists. We present a case of a 17-year-old boy with chronic osteomyelitis involving the right proximal ulna. During an irrigation and debridement operation, a frozen section was sent to surgical pathology for evaluation. A limited patient history coupled with sparse organisms present in the frozen section led to the diagnosis of fungal osteomyelitis, favor Coccidioides . Follow-up permanent sections with special staining and successful fungal culture clarified the causal agent to be Blastomyces dermatitidis . The role of frozen sections is not to perfectly speciate the fungal pathogen but to describe the morphology and infectious process and provide a differential diagnosis of the candidate fungi. The importance of intraoperative culture in infectious cases cannot be understated, and it is the responsibility of pathologists to inform surgeons that tissue is needed for culture. A brief overview of Blastomyces , including histopathologic features and key microscopic differences from Coccidioides and Cryptococcus , is discussed.