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Ann Thorac Surg 2004;78:1760
© 2004 The Society of Thoracic Surgeons

INVITED COMMENTARY

Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St, SW, Rochester, MN 55905, USA

Francis C. Nichols, III, MD

Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St, SW, Rochester, MN 55905, USA

schipperp{at}msnotes.wustl.edu
nichols.francis{at}mayo.edu

Technical advances in chest imaging combined with lung cancer screening trials are bringing ever-smaller pulmonary nodules to light. Although positron emission tomography (PET) and transthoracic needle aspiration (TTNA) may assist in the differentiation of benign from malignant nodules, definitive diagnosis of many pulmonary nodules cannot be determined until they are surgically removed and pathologically examined. Quick, thorough, and accurate pathological diagnosis is essential in the surgical management of pulmonary nodules so appropriate resection can be accomplished at the time of initial wedge resection under the same general anesthetic.

The technique of frozen section surgical pathology is more than 100 years old and available worldwide. Nonetheless, this time-proven technique is only selectively utilized in most surgical and pathological practices. Our practice is unique in that nearly all surgical specimens obtained from the operating rooms are examined by frozen section [1]. Errors in frozen section, that is a change in the pathology report from frozen to permanent section, can be placed into one of three categories. First is a change in the degree of abnormality such as a change in tumor grade, histologic type, or local stage. Second are sampling errors ultimately identified by further tissue sectioning. Third are true misinterpretations with a change in diagnosis upon review of permanent sections.

The real question is when one of these errors occurs, does it have a clinically significant impact on the patient? Would the corrected diagnosis have altered the intraoperative decision making to a different conclusion? In 1993 at our institution, there were 24,880 frozen section surgical pathology reports. After examination of permanent sections 31 reports (0.1%) changed due to clinically significant errors. None resulted in serious harm to the patient [1]. These results were similar to other studies of diagnostic accuracy where permanent sections were analyzed.

In the current article, Marchevsky and colleagues reassure us that frozen section is an accurate diagnostic tool for most pulmonary nodules, including many small nodules. Nevertheless, the shortcomings of frozen section pathology appear to be primarily small pulmonary nodules with diagnoses of bronchoalveolar carcinoma (BAC), or atypical adenomatous hyperplasia (AAH). The controversy over the natural history of AAH and small BAC's is beyond the scope of this article. The analogy the authors draw between small breast lesions and small lung nodules may not be appropriate and is not consistent with our surgical pathology practice. We certainly agree that there is an exponential magnitude of difference between a wedge resection of the lung and a breast biopsy. The authors have pointed out the challenges facing both thoracic surgeons and surgical pathologists in the management of these entities. Surgical pathologists need to appreciate the thoracic surgeon's need for an accurate, definitive diagnosis at the time of initial pulmonary wedge resection. Thoracic surgeons need to understand their institution's frozen section capabilities, and the limitations of the surgical pathologists as we challenge them with increasingly smaller pulmonary nodules. An open dialogue between the two along with the application of sound clinical judgment will hopefully help avoid clinically significant errors.

References

1. Ferreiro JA, Myers JL, Bostwick DG. Accuracy of frozen section diagnosis in surgical pathology: review of a 1-year experience with 24,880 cases at Mayo Clinic Rochester. Mayo Clin Proc. 1995;70:1137–1141[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Paul H. Schipper Francis C. Nichols, III Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Schipper, P. H. Articles by Nichols, F. C. Search for Related Content PubMed PubMed Citation Articles by Schipper, P. H. Articles by Nichols, F. C., III Related Collections Lung - cancer