Lessons Learned From Mistakes and Deferrals in the Frozen Section Diagnosis of Bronchioloalveolar Carcinoma and Well-Differentiated Pulmonary Adenocarcinoma

Gupta, Ruta; McKenna, Robert J.; Marchevsky, Alberto M.

doi:10.1309/uuh2xheckevd45pf

Cited by 37 publications

(25 citation statements)

References 21 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Most papers specifically dealing with frozen section analysis of lung lesions f2 cm originate from Japan. In a review by GUPTA et al [41] including nodules examined over a 5-yr period, the error rate was 1.6% and deferral rate 4.4%. In the other papers summarised in table 3, predictive value ranged from 93% to 100%, but not all studies clearly mention accuracy of frozen section analysis.…”

Section: Intraoperative Frozen Section Analysis Diagnostic Accuracymentioning

confidence: 97%

“…Few articles deal with the exact procedure of intraoperative frozen section examination and its accuracy. These are summarised in table 3 [36][37][38][39][40][41][42][43][44][45][46][47][48]. Most papers specifically dealing with frozen section analysis of lung lesions f2 cm originate from Japan.…”

Section: Intraoperative Frozen Section Analysis Diagnostic Accuracymentioning

confidence: 99%

See 1 more Smart Citation

Surgical implications of the new IASLC/ATS/ERS adenocarcinoma classification

Asamura²,

et al. 2011

View full text Add to dashboard Cite

A new adenocarcinoma classification was recently introduced by a joint working group of the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society (ATS) and European Respiratory Society (ERS). A distinction is made between pre-invasive lesions, and minimally invasive and invasive adenocarcinoma. The confusing term ''bronchioloalveolar carcinoma'' is not used any more and new subcategories include adenocarcinoma in situ and minimally invasive adenocarcinoma.Due to a renewed interest in screen-detected nodules and early-stage lung cancers of ,2 cm, this classification also has profound implications for thoracic surgeons.In this article, surgical topics are discussed: the role of a minimally invasive approach, especially video-assisted thoracic surgery, limited resection for early-stage lung cancer, the extent of lymph node dissection, the accuracy of intraoperative frozen section analysis, management of multiple lung nodules and prognostic factors in operated patients. Specific key issues are presented based on the current evidence and areas of surgical uncertainty are defined providing a basis for further studies.Thoracic surgeons will play a major role in the application and global introduction of this new adenocarcinoma classification. The remaining controversies regarding the precise diagnosis and management of early-stage lesions will have to be resolved by multidisciplinary and international collaboration.

show abstract

Section: Intraoperative Frozen Section Analysis Diagnostic Accuracymentioning

confidence: 97%

Section: Intraoperative Frozen Section Analysis Diagnostic Accuracymentioning

confidence: 99%

Surgical implications of the new IASLC/ATS/ERS adenocarcinoma classification

Asamura²,

et al. 2011

View full text Add to dashboard Cite

show abstract

“…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. In their study, bronchioloalveolar carcinoma-well differentiated adenocarcinoma was considered the same diagnosis, and the problem was to distinguish these lesions from reactive atypia.…”

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.…”

mentioning

confidence: 99%

See 1 more Smart Citation

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

Self Cite

View full text Add to dashboard Cite

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.

show abstract

Evidence‐based evaluation of the risks of malignancy predicted by thyroid fine‐needle aspiration biopsies

Marchevsky

Walts

Bose

et al. 2009

Diagnostic Cytopathology

View full text Add to dashboard Cite

A National Cancer Institute (NCI) "Thyroid Fine-Needle Aspiration (FNA) State of the Science Conference" recently proposed standardized nomenclature and "risks of malignancies" associated with various diagnostic categories. We evaluated the evidence levels of the data used by NCI to predict malignancy risks and whether those estimates had clinical validity in our patient population.Eight hundred seventy-nine patients underwent thyroid FNA during 2006. FNA diagnoses were translated into NCI diagnostic categories, and 2-year follow-up retrospective information was obtained. Four percentages of malignancies were calculated for each diagnostic category using follow-up information from FNA, thyroidectomy, both, and all patients as denominators. 95% confidence intervals (CI) were estimated for all proportions, and results were analyzed with chi-square statistics. "Relative risk" calculations were performed using the percentage of malignancies in the entire population under study as a denominator.Most of the studies cited by the NCI provided incomplete and variable level III evidence based mainly on surgical follow-up. Among our patients, the percentages of malignancies calculated with follow-up data from all patients as the denominator were similar to the "risk estimates" proposed by the NCI, but estimates based on surgical follow-up overestimated the probability of thyroid malignancy for patients with FNA diagnosis of "benign" and "follicular lesions of undetermined significance" (FLUS). Relative risk and 95% CI calculations suggested that the NCI classification could be simplified into three categories: "benign," "FLUS + neoplasm," and "suspicious + malignant."

show abstract

Lessons Learned From Mistakes and Deferrals in the Frozen Section Diagnosis of Bronchioloalveolar Carcinoma and Well-Differentiated Pulmonary Adenocarcinoma

Cited by 37 publications

References 21 publications

Surgical implications of the new IASLC/ATS/ERS adenocarcinoma classification

Surgical implications of the new IASLC/ATS/ERS adenocarcinoma classification

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

Evidence‐based evaluation of the risks of malignancy predicted by thyroid fine‐needle aspiration biopsies

Contact Info

Product

Resources

About