Frozen Section Diagnoses of Small Pulmonary Nodules: Accuracy and Clinical Implications

Marchevsky, Alberto M.; Changsri, Chanikarn; Gupta, Indu; Fuller, Clark; Houck, Ward V.; McKenna, Robert J.

doi:10.1016/j.athoracsur.2004.05.003

Cited by 100 publications

(93 citation statements)

References 19 publications

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“…In the trial reported by YOSHIDA et al [61], this intra-operative assessment took ,1 h. There was agreement with the definitive post-operative pathological study in all specimens but one, which was changed from Noguchi's type B to C. However, other authors have reported difficulties in assessing the difference between BAC, atypical adenomatous hyperplasia, peripheral carcinoid tumours and other lesions [65]. If the intra-operative diagnosis of BAC is certain to the best of the pathologist's knowledge, then, according to the results of the series shown in table 2, a sublobar resection with no nodal dissection may be enough to ensure complete resection.…”

Section: Combined Therapiesmentioning

confidence: 52%

Sublobar resection for lung cancer

Rami–Porta

Tsuboi²

2009

Eur Respir J

102

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Sublobar resection for small lung cancers has been debated frequently and is still a controversial issue. The only randomised trial comparing lobectomy with sublobar resections found a significantly higher recurrence rate for the latter, but failed to show significant differences in survival, although survival was better for the lobectomy group. One meta-analysis and several nonrandomised comparisons have confirmed these results. In general, lobectomy and sublobar resections have similar 5-yr survival rates. Local recurrence after wedge resection is higher than after segmentectomy. However, for patients aged .71 yrs, lobectomy and wedge resection are associated with similar survival. For tumours of f2 cm, segmentectomy is equivalent to lobectomy, but survival after segmentectomy is worse if performed for larger tumours. For both segmentectomy and wedge resection, tumour margins should be o1 cm wide to avoid recurrence. For pure bronchioloalveolar carcinoma of f2 cm, diagnosed intraoperatively with certainty, sublobar resection seems equivalent to lobectomy, and because there is no nodal involvement, systematic nodal dissection may not be necessary. In case of doubt, however, lobectomy with systematic nodal dissection will ensure complete resection and adequate staging. More randomised trials are needed to confirm all these issues.

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Section: Combined Therapiesmentioning

confidence: 52%

Sublobar resection for lung cancer

Rami–Porta

Tsuboi²

2009

Eur Respir J

102

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“…Problems in the frozen section diagnosis of lung lesions have previously been investigated in our laboratory [5][6][7] and by others. 15 In a review of frozen sections performed on 183 small (,1.5 cm) lung nodules, Marchevsky et al 5 concluded that the distinction between bronchioloalveolar carcinoma (currently adenocarcinoma in situ) and atypical adenomatous hyperplasia was often problematic, and that the diagnostic accuracy was lowest for small (,1.1 cm) lesions.…”

Section: Clinical Impact Of Frozen Section Errors and Deferralsmentioning

confidence: 99%

“…15 In a review of frozen sections performed on 183 small (,1.5 cm) lung nodules, Marchevsky et al 5 concluded that the distinction between bronchioloalveolar carcinoma (currently adenocarcinoma in situ) and atypical adenomatous hyperplasia was often problematic, and that the diagnostic accuracy was lowest for small (,1.1 cm) lesions. In a subsequent study, Gupta et al 6 used an evidence-based approach to identify 5 features (multiple growth patterns, anisocytosis, atypia involving .75% of the lesion, macronucleoli, and atypical mitoses) that were most useful in distinguishing bronchioloalveolar carcinoma-well differentiated adenocarcinoma from reactive atypia in frozen sections.…”

Section: Clinical Impact Of Frozen Section Errors and Deferralsmentioning

confidence: 99%

“…Hence, in our hospital, pathologists are frequently asked not only to make the initial diagnosis of pulmonary malignancy at intraoperative frozen section but also to distinguish between in situ, minimally invasive, and invasive adenocarcinoma, a task that is difficult and fraught with potential errors. [5][6][7] As this classification is still in a period of validation, the role of frozen section in the diagnosis of in situ and minimally invasive adenocarcinoma remains investigational. To our knowledge, no root-cause analysis data on errors and deferrals in the frozen section diagnosis of these lesions, using the newly proposed classification, have appeared in the literature.…”

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confidence: 99%

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Root Cause Analysis of Problems in the Frozen Section Diagnosis of In Situ, Minimally Invasive, and Invasive Adenocarcinoma of the Lung

Walts

Marchevsky

2012

Archives of Pathology &Amp; Laboratory Medicine

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Context.-Frozen sections can help determine the extent of surgery by distinguishing in situ, minimally invasive, and invasive adenocarcinoma of the lung.Objective.-To evaluate our experience with the frozen section diagnosis of these lesions using root-cause analysis.Design. Results.-There were no false-positive diagnoses of malignancy. Frozen section errors and deferrals were identified in 12.1% (27 of 224) and 6.3% (14 of 224) of the cases, respectively. Significantly more errors occurred in the diagnosis of in situ and minimally invasive adenocarcinoma than in the diagnosis of invasive adenocarcinoma (P , .001). Frozen section errors and deferrals were twice as frequent in lesions smaller than 1.0 cm (P ¼ .09). Features significantly associated with errors and deferrals included intraoperative consultation by more than one pathologist (P ¼ .003) and more than one sample of frozen lung section (P ¼ .001). Inflammation with reactive atypia, fibrosis/scar, sampling problems, and suboptimal quality sections were identified in 51.2% (21 of 41), 36.6% (15 of 41), 26.8% (11 of 41), and 9.8% (4 of 41) of the errors and deferrals, respectively (more than one of these factors was identified in some cases). Frozen section errors and deferrals had significant clinical impact in only 4 patients (1.8%); each had to undergo completion video-assisted thoracoscopic lobectomy less than 90 days after the initial surgery.Conclusions.-The distinction of in situ from minimally invasive adenocarcinoma is difficult in both frozen and permanent sections. We identified several technical and interpretive features that likely contributed to frozen section errors and deferrals and suggest practice modifications that are likely to improve diagnostic accuracy.

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“…In one study, the sensitivity for identifying malignancy was 87% for nodules that measured , 1.1 cm in diameter and 94% for nodules that measured between 1.1 and 1.5 cm. 112 The technique has limitations in distinguishing minimally invasive adenocarcinoma or adenocarcinoma in situ (AIS) from atypical adenomatous hyperplasia (AAH) and in establishing a specifi c cell type in nonsmall cell carcinoma. It is limited in recognizing small peripheral carcinoid tumors.…”

Section: From Steinfort Et Al L01mentioning

confidence: 99%

Evaluation of Individuals With Pulmonary Nodules: When Is It Lung Cancer?

Gould

Donington

Lynch

et al. 2013

Chest

1,163

1,089

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we suggest that no additional diagnostic evaluation need be performed (Grade 2C) .Remark : This recommendation applies only to solid nodules. For guidance about follow-up of subsolid nodules, see Recommendations 6.5.1 to 6.5.4 . 2.3.3.In the individual with an indeterminate nodule that is identifi ed by chest radiography, we recommend that CT of the chest should be performed (preferably with thin sections Objectives: The objective of this article is to update previous evidence-based recommendations for evaluation and management of individuals with solid pulmonary nodules and to generate new recommendations for those with nonsolid nodules. Methods: We updated prior literature reviews, synthesized evidence, and formulated recommendations by using the methods described in the "Methodology for Development of Guidelines for Lung Cancer" in the American College of Chest Physicians Lung Cancer Guidelines, 3rd ed. Results: We formulated recommendations for evaluating solid pulmonary nodules that measure . 8 mm in diameter, solid nodules that measure Յ 8 mm in diameter, and subsolid nodules. The recommendations stress the value of assessing the probability of malignancy, the utility of imaging tests, the need to weigh the benefi ts and harms of different management strategies (nonsurgical biopsy, surgical resection, and surveillance with chest CT imaging), and the importance of eliciting patient preferences. Conclusions: Individuals with pulmonary nodules should be evaluated and managed by estimating the probability of malignancy, performing imaging tests to better characterize the lesions, evaluating the risks associated with various management alternatives, and eliciting their preferences for management. CHEST 2013; 143(5)(Suppl):e93S-e120SAbbreviations: AAH 5 atypical adenomatous hyperplasia; ACCP 5 American College of Chest Physicians; AIS 5 adenocarcinoma in situ; EBUS 5 endobronchial ultrasound; ENB 5 electromagnetic navigation bronchoscopy; FDG 5 fl uorodeoxyglucose; HU 5 Hounsfi eld unit; LR 5 likelihood ratio; SPECT 5 single-photon emission CT; TBB 5 transbronchial biopsy; TTNB 5 transthoracic needle biopsy; VATS 5 video-assisted thoracic surgery; VBN 5 virtual bronchoscopy navigation; VDT 5 volume doubling time

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Frozen Section Diagnoses of Small Pulmonary Nodules: Accuracy and Clinical Implications

Cited by 100 publications

References 19 publications

Sublobar resection for lung cancer

Sublobar resection for lung cancer

Root Cause Analysis of Problems in the Frozen Section Diagnosis of In Situ, Minimally Invasive, and Invasive Adenocarcinoma of the Lung

Evaluation of Individuals With Pulmonary Nodules: When Is It Lung Cancer?

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