Crazy-Stupid Frozen Sections

[NuckingFuts]

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I'm at an academic center and we routinely do frozens on skin margins for melanoma.

How many of you gals on this forum do these types of frozens?

 

[KeratinPearls]

I'm at an academic center and we routinely do frozens on skin margins for melanoma.

How many of you gals on this forum do these types of frozens?

I just want to say that I love your screenname NuckingFuts!!!

 

[NuckingFuts]

I just want to say that I love your screenname NuckingFuts!!!

👍 cheers mate

 

[sohsie]

Where I trained every once in a long while some surgeon would ask for a frozen for margins for melanoma and the pathologists would refuse to do it. There would be major fireworks and lots of four letter words flying out of the surgeons mouths along with all sorts of threats of recrimination but the pathologists always refused to back down.

 

[NuckingFuts]

Here's another one- a urologist requests a frozen for a margin on a partial nephrectomy when they know damn well they 1) can't give more and/or 2) haven't consented the patient to a total nephrectomy.

 

[pathstudent]

Got called in on a Saturday late morning for a lung nodule biopsy. Clinical was "rule out wegeners". It looked good for wegeners but knew that a lot of other stuff would have to be ruled out. I Walked into the or room to tell the surgeon he had a good biopsy that would provide diagnostic tissue and that he should also get some for culture, but he had three more wedges for permanent and the patient was already being woken up by anesthesia. He sees me and says "is it wegeners?" and I try to explain to him you can't really diagnose wegeners on pathology alone and certainly not on frozen section. He keeps on asking me "yeah but is it wegeners?". I wanted to ask him "now why did I need to come in for this" but of course I bit my tongue and said we would rush it for Monday am. I guess the only good thing is I was able to cassette the other three other wedges so they could be out on Monday.

 

[TJMAXX]

is it wegeners?"

 

[Pathologee]

I once had to freeze a section of endometrium from a uterus to see if a) it was cancer b) if there was any invasion, and c) the depth of invasion compared to the thickness of the myometrium. Sheesh.

 

[gbwillner]

Not exactly a frozen, but I was asked to open an ovarian serous cystadenoma the size of a watermelon in the OR (before sampling a frozen). I said it wouldn't be a good idea. They said to do it- I said not unless you have the custodial staff on-hand for a STAT clean-up, or unless the OR staff had galoshes on. They relented and allowed me to open it in the sink in the frozen area.

 

[Ishie1013]

I'm thinking of proposing a slapping policy for the second offense of freezing lung granulomas, particularly without labeling them as such.

"Dear sirs. While I realize that you're not concerned about our exposure to TB, we would humbly ask that you not mothball our cryostats for the next 24 hours."

 

[NuckingFuts]

Chairman of surgery operated today, took out a portion of liver with a mass 3 cm from the resection margin. Patient has hx of colon and endometrial ca.

Chairman requests a frozen, after the patient is closed up and in post-op, and wants to know what the met is, so he can- in his own words- "tell the family."

 

[TMZ2007]

Chairman of surgery operated today, took out a portion of liver with a mass 3 cm from the resection margin. Patient has hx of colon and endometrial ca.

Chairman requests a frozen, after the patient is closed up and in post-op, and wants to know what the met is, so he can- in his own words- "tell the family."

And you told him "poorly-differentiated malignancy, defer to permanents", right?

 

[NuckingFuts]

And you told him "poorly-differentiated malignancy, defer to permanents", right?

you got it buddy

 

[deleted314957]

In the same vein, I had a very intellectually lazy oncologist (and, unbelieveably, former pathologist who seemed to know NOTHING about pathology) ask me to do a bone marrow on a small cell lung ca patient with demonstrable brain mets so he could be staged.
needless to say, the pt did not suffer thru a marrow.

 

[Euchromatin]

Some ortho surgeon paged on a Sunday afternoon one time and wanted us to freeze a bone/bone marrow specimen on a child to see if he had leukemia/lymphoma...I wish I could have heard how the attending I was on call with told him no over the phone.

On big sarcoma specimens that are often 15-20 cm in greatest dimension, we get "margins" to freeze that are often only 1-2 cm...our orthopedic oncologist also gets irritated when we don't give her very specific diagnoses on frozens of bony curettings (bonus points - she never puts any of the patient's imaging findings in the EMR, so the only time we see them is if they happen to be on a screen in the OR when we pop to get the specimen).

 

[lipomas]

I once had to freeze a section of endometrium from a uterus to see if a) it was cancer b) if there was any invasion, and c) the depth of invasion compared to the thickness of the myometrium. Sheesh.

That's actually a legitimate request though. Deeper invasion in some literature means you need to do more aggressive staging. Your example is a FAIL.


Some good examples from our place:
1) Thyroid frozen. I'm doing the other lobe anyway but wanted to see if this was really cancer (FNA was positive for PTC).
2) Core of bone in a patient with a sclerotic bone tumor. We can't freeze bone Surgeon: Why not?
3) Asking for a bronchial margin on a completion lobectomy for a 1 cm peripheral adenocarcinoma that was excised for diagnostic purposes with 3cm margins in a wedge.
4) "Margins" on a well differentiated liposarcoma re-resection. I think that one takes the cake.
5) Mucosal margin on a laryngeal chondrosarcoma resection. UH DURRRRR...
6) 5 cm entire lymph node sent down. Just want to know if I have diagnostic tissue. OKAY!!

 

[lipomas]

BTW frozens on skin margins of melanoma sounds like just about the worst thing I could ever imagine. Much worse than bile duct margins in PSC patients with stents in place.

 

[NuckingFuts]

That's actually a legitimate request though. Deeper invasion in some literature means you need to do more aggressive staging. Your example is a FAIL.


Some good examples from our place:
1) Thyroid frozen. I'm doing the other lobe anyway but wanted to see if this was really cancer (FNA was positive for PTC).
2) Core of bone in a patient with a sclerotic bone tumor. We can't freeze bone Surgeon: Why not?
3) Asking for a bronchial margin on a completion lobectomy for a 1 cm peripheral adenocarcinoma that was excised for diagnostic purposes with 3cm margins in a wedge.
4) "Margins" on a well differentiated liposarcoma re-resection. I think that one takes the cake.
5) Mucosal margin on a laryngeal chondrosarcoma resection. UH DURRRRR...
6) 5 cm entire lymph node sent down. Just want to know if I have diagnostic tissue. OKAY!!

Sadly, most of those examples sound familiar.

 

[Alteran]

1. Surgeon is doing an orbital BCC resection on a pt whose cardiac performance status is one grade better than rotten meat. Pathology shows up and is given 18 frozen sections at once...surgeon wants the results STAT. 😱

2. Gyn/Onc keeps hallucinating tumors in patients that aren't even seeing them for an oncology problem in the OR.

3. Thyroid surgeon calls for frozen on left lobe and is found to be benign (surgeons were sure they got papillary carcinoma). Before pathology got to relay results, patient is already in recovery and we're handed the other lobe. Only because the divine one was looking out for them that day did we find the smallest possible focus of papillary carcinoma in the right lobe.

4. Actual conversation:
Surgeon: Need a frozen section on this lung wedge, diagnosis and margin(s)
Pathologist: You have necrotizing granulomas, negative for malignancy
Surgeon: Oh yeah, this patient has history of TB
Pathologist:

 

[maji]

We have one surgeon who sends staging mediastinoscopy lymph nodes for frozen, all of them. He has no plans to continue to a lung resection if they are negative... but wants to tell the family.

Even after the recent breast trials showing frozens on breast sentinel nodes aren't that useful, we still have a few surgeons doing them.

Plenty of examples of late frozens, not on the schedule, that when you call back, the surgeon and patient are out of the room.

I got a mastectomy for intraop consult. They wanted to know if they got all the lesions out. This breast had like 6 clips in it from a barrage of biopsies. I essentially grossed it fresh, went to xray to find the clips and locate the lesions. The surgeon was upset that it took awhile to actually do that...

Weekend frozens on ovarian cysts/torsion are common. But after we called the ovary negative, and mentioned there were fibroids, the surgeon requested a frozen on a fibroid...

I was once paged on call to go back to work to weigh a fibroid uterus, since the OR scale couldnt handle it.. Hardly something that is urgent.

 

[Kunu]

One group I interviewed at said they routinely are called in the middle of the night by the ED to freeze POC's.

 

[2121115]

One group I interviewed at said they routinely are called in the middle of the night by the ED to freeze POC's.

Pretty common request actually.

 

[twentyone]

Here's my favorite frozen request:
The person had checked "yes" to frozen on the req. sheet but then wrote in "only if there's cancer."
Wrap your heads around that one.

 

[deleted314957]

Oh for the (distant) past when surgeons had to do at least a modicum of path in their training. (in the FAR distant past, they did the path like pre Dr Lauren Ackerman)

 

[Apollyon]

One group I interviewed at said they routinely are called in the middle of the night by the ED to freeze POC's.

Pretty common request actually.

Really? I'm an EM attending, and I have never called path for anything. If I get POCs, they go in a specimen container and go off to path from there.

If it is a tech from the lab calling, that is something else.

And if I an missing the point (i.e. what I write is what you mean), apologies.

 

[deleted314957]

upon which i would tell him that is not my practice ( you can get away with that when you've been the chief for 22 years) re: the salivary gland post

 

[pathstudent]

Really? I'm an EM attending, and I have never called path for anything. If I get POCs, they go in a specimen container and go off to path from there.

If it is a tech from the lab calling, that is something else.

And if I an missing the point (i.e. what I write is what you mean), apologies.

I have only seen a POC frozen one time and it was not from the ED.

 

[dermpathdoc]

I'm thinking of proposing a slapping policy for the second offense of freezing lung granulomas, particularly without labeling them as such.

"Dear sirs. While I realize that you're not concerned about our exposure to TB, we would humbly ask that you not mothball our cryostats for the next 24 hours."

For threads like this I wish there was a Facebook "like" button!

 

[deleted57552]

Freezing POCs to document villi thereby ruling out ectopic pregnancy happens at some institutions. Not as uncommon as you think.

Might happen more at places where the emphasis on tissue confirmation on practically anything is overboard. This is a consequence of clinicians being burned for making poor decisions (i.e., removing fallopian tubes based on inconclusive data for supposed tubal pregnancies that end up not having any products of conception).

According to a friend who used to be at a high profile department on the east coast, this happens not too infrequently there.

 

[Apollyon]

Really? I'm an EM attending, and I have never called path for anything. If I get POCs, they go in a specimen container and go off to path from there.

If it is a tech from the lab calling, that is something else.

And if I an missing the point (i.e. what I write is what you mean), apologies.

To be quite honest, I misspoke. I have never called a pathologist for something like this. I DID call path for advice on how to submit a Tzanck smear to our lab (before my hospital closed down).

 

[yaah]

We talk to the ED a lot, mostly about lab test ordering, what tests are available, things like that.

 

[MOHS_01]

Frozens on melanoma suck -- particularly for LM. I've argued with colleagues for years that they are inadequate. Immunos help, but how many derm offices do you believe perform them perfectly every time? In my estimation frozens have about a 90-95% concordance rate with permanents for LM; on first blush that sounds acceptable... but if you're doing five of these a week a couple times a month you're telling someone at suture removal:" You know, I did tell you it looked like we got it all. Well... I was wrong about that. Sorry."

Not good.

 

[aplasticcrisis]

Where I trained in residency we'd do something for the GI surgery team called "open and return." They'd send some colon or rectal resection and want it measured, inked and opened with a report of the size and location of the lesion. We'd then package the specimen up and send it back to the OR along with the gross report. The surgeons wanted this since they fancied themselves amateur photographers and wanted to photograph the tumors themselves. Apparently our own gross room photos did not suffice.

We'd do all sorts of assinine frozens too such as margins for breast lumpectomies, margins for melanoma, lung wedges where the surgeons already cut into the wedge in the OR to show the medical students what a "tumor" looks like (1/3 of them ended up being granulomas on frozen anyway. I wonder how many students and OR staff seroconverted.) Tons of waste of time GYN frozens on teratomas and endometrial carcinoma.

 

[deleted314957]

I really don't see how people get pushed into frozens for melanocytic lesions. there is plenty of reference material that damned near says it is almost malpractice/below the standard of care to do that. the clinician should be so informed and be grateful that you have the best interest of the patient in mind. if, THEN, they want to be a hard case, tell her/him you will take it up with the physician practice performance review committee or whatever you call it and see if that changes her mind. if not , do frozen, defer dx and follow thru. you do not need to be a ****ing DOORMAT.

 

[MOHS_01]

I really don't see how people get pushed into frozens for melanocytic lesions. there is plenty of reference material that damned near says it is almost malpractice/below the standard of care to do that. the clinician should be so informed and be grateful that you have the best interest of the patient in mind. if, THEN, they want to be a hard case, tell her/him you will take it up with the physician practice performance review committee or whatever you call it and see if that changes her mind. if not , do frozen, defer dx and follow thru. you do not need to be a ****ing DOORMAT.

Wait -- are folks really doing the frozens and that's it? Or are they always doing definitive permanents?

 

[NuckingFuts]

I really don't see how people get pushed into frozens for melanocytic lesions. there is plenty of reference material that damned near says it is almost malpractice/below the standard of care to do that. the clinician should be so informed and be grateful that you have the best interest of the patient in mind. if, THEN, they want to be a hard case, tell her/him you will take it up with the physician practice performance review committee or whatever you call it and see if that changes her mind. if not , do frozen, defer dx and follow thru. you do not need to be a ****ing DOORMAT.

A friend at a low/mid-tier academic institution said she did just that. Nothing happened. Why? Because the impotent hospital administration was afraid the surgeons would begin taking their patients to another place down the street.

No big surprise there- the mighty dollar ranks above patient care.

 

[NuckingFuts]

Wait -- are folks really doing the frozens and that's it? Or are they always doing definitive permanents?

By the way MOHS_01, judging from your avatar you may appreciate that I always repeat the phrase "you never go full-******' every single time I get called for an inappropriate frozen.

 

[LADoc00]

I'm at an academic center and we routinely do frozens on skin margins for melanoma.

How many of you gals on this forum do these types of frozens?

Ummm...dude this isnt unusual....

How about these frozens:

Craziest FS practices of all time1.) Crazed OB ordering frozens on all POCs, when confronted will not state why
2.) Dermatologist who orders FS on skin bx for r/o Scabies
3.) Ortho who insists on the impossible FS on bone lesions
4.) Breast surgeon who insists on FS on micromets to sentinel nodes of lobular carcinoma
5.) Internist who routinely orders "Frozens" on dead people because the family won't pay for an autopsy, even to the point of requesting bodies are exhumed for "Frozens"

 

[mlw03]

I once had to freeze a section of endometrium from a uterus to see if a) it was cancer b) if there was any invasion, and c) the depth of invasion compared to the thickness of the myometrium. Sheesh.

Where I did residency this exact frozen was a regular specimen.

 

[2121115]

Where I did residency this exact frozen was a regular specimen.

The post you are responding to was a joke, BTW.