Cytology sucks

[LADoc00]

Cytology is the "Emperor's New Clothes" of Path.

Everyone around me pretends to see the illusionary enlarged hyperchromatic nuclei. Join me in prayer for the end of pap smears, breast and soft tissue FNAs. They are a scourge upon us.

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[pathdawg]

C'mon dude. Cyto isn't all that bad. All you need is a little knowledge (and alot of imagination).

Cytology is the "Emperor's New Clothes" of Path.

Everyone around me pretends to see the illusionary enlarged hyperchromatic nuclei. Join me in prayer for the end of pap smears, breast and soft tissue FNAs. They are a scourge upon us.

 

[DrBloodmoney]

That's all it is

 

[pathdawg]

Cytology is the "Emperor's New Clothes" of Path.

Everyone around me pretends to see the illusionary enlarged hyperchromatic nuclei. Join me in prayer for the end of pap smears, breast and soft tissue FNAs. They are a scourge upon us.

Speaking of the emperor's new clothes phenomenon, how about hemepath? Can we make up some more new and unnecessary immuno stains? I am working up a lymphoma case and the hemepath guy says to get a CD21 stain on top of the other 8 stains I am getting. I ask "what does it tell us" and the response is, "it'll highlight dentritic cells in the follicle." And that tells us..........NOTHING!!! Do they just do that to up the billing, or is it just mental masterbation?

 

[LADoc00]

Speaking of the emperor's new clothes phenomenon, how about hemepath? Can we make up some more new and unnecessary immuno stains? I am working up a lymphoma case and the hemepath guy says to get a CD21 stain on top of the other 8 stains I am getting. I ask "what does it tell us" and the response is, "it'll highlight dentritic cells in the follicle." And that tells us..........NOTHING!!! Do they just do that to up the billing, or is it just mental masterbation?

Dude dont even go there, the interobserver agreement among hematopathologists is VASTLY better than cytology. And CD21 is an absurdly important stain especially when expanded in Angioimmunoblastic T cell lymphoma.

So, go back to enjoying your "hyperchromatic crowded groups."

SEE BELOW

CMS Clarifies Cytology Proficiency Testing Requirements for Residents/Fellows


In March 2005, CMS determined that the requirements for residents and fellows in Cytopathology programs to participate in a CMS-approved Cytology Proficiency Testing Program include the following: Residents would not be required to participate in a CMS-approved Cytology Proficiency Testing Program. Pathology residents are not board-certified and are under the constant supervision of fully licensed physicians.


CMS also stated that since fellows in Cytopathology programs have completed their residency and have increasing responsibilities in the cytology laboratory, participation in proficiency testing may be required. Specifically, those Fellows whose responsibilities in the laboratory include the examination and final diagnosis of gynecologic specimens must enroll and participate in a CMS-approved Cytology Proficiency Testing Program. Fellows who do not render a final diagnosis on gynecologic specimens are not required to participate in a CMS-approved Cytology Proficiency Testing Program.


The CMS ruling is based on information submitted by the Accreditation Council for Graduate Medical Education and the American Board of Pathology, and communications with the cytology community.

How ******ed is this? Why even HAVE A BOARD CERTIFICATION in cytology if you have to get additional government certification to analyze pap smears.

Listen to me know and understand me later: Send your cytology OUT. Its a high liability, no pay debacle.

 

[RyMcQ]

How ******ed is this? Why even HAVE A BOARD CERTIFICATION in cytology if you have to get additional government certification to analyze pap smears.

Okay, this is like the tenth time I have agreed with you today. (Scary.)

I didn't like the hot carl pic, though.

 

[pathdawg]

Dude dont even go there, the interobserver agreement among hematopathologists is VASTLY better than cytology. And CD21 is an absurdly important stain especially when expanded in Angioimmunoblastic T cell lymphoma.

So, go back to enjoying your "hyperchromatic crowded groups."

SEE BELOW


How ******ed is this? Why even HAVE A BOARD CERTIFICATION in cytology if you have to get additional government certification to analyze pap smears.

Listen to me know and understand me later: Send your cytology OUT. Its a high liability, no pay debacle.

You crack me up, man. First of all, I was working up a damn B-cell NHL, not a T-cell angioimmunoblastic whatever. Secondly, heme is waaaaay too unnecessarily complicated. Cyto is straightforward. You follow certain criteria and make a dx without having to cut somebody open. If you think about it, thats pretty cool. With heme, you have to get about 12 IHC stains, then get flow, then get cytogenetics, then get B- and T-cell rearrangment PC-frickin' R studies. WTF! Make a damn call already without spending tens of thousands of dollars. Jeeech.

 

[LADoc00]

You crack me up, man. First of all, I was working up a damn B-cell NHL, not a T-cell angioimmunoblastic whatever. Secondly, heme is waaaaay too unnecessarily complicated. Cyto is straightforward. You follow certain criteria and make a dx without having to cut somebody open. If you think about it, thats pretty cool. With heme, you have to get about 12 IHC stains, then get flow, then get cytogenetics, then get B- and T-cell rearrangment PC-frickin' R studies. WTF! Make a damn call already without spending tens of thousands of dollars. Jeeech.

Dats why cytologists be poh, they dont realize immunos=$$$.

 

[Gran Turismo]

Cytology is the "Emperor's New Clothes" of Path.

Everyone around me pretends to see the illusionary enlarged hyperchromatic nuclei. Join me in prayer for the end of pap smears, breast and soft tissue FNAs. They are a scourge upon us.

I think neuropath might be worse. Try getting a job with those credentials. Its not like you can just go around stabbing a needle in people's brains everyday. I hear the only way to get a job in neuropath is if someone dies.

 

[gungho]

Cytology is the "Emperor's New Clothes" of Path.

Everyone around me pretends to see the illusionary enlarged hyperchromatic nuclei. Join me in prayer for the end of pap smears, breast and soft tissue FNAs. They are a scourge upon us.

Interesting comment. I have had the same thoughts, but being 1st year, figured "what do I know" and it'll all become clear later. But I enjoyed my 1st Cytology rotation-helped me understand some fundamentals regarding neoplasia and correlations in histology.

 

[pathdawg]

Dats why cytologists be poh, they dont realize immunos=$$$.

Oh...THATS why I can't make ends meet. Thanks LA!

Time to order me up some immunos!

 

[yaah]

My limited exposure to cytology so far has been very unenlightening. I just don't like it, and don't find it interesting. Am I stuck with academics if I don't like either hemepath or cyto and I don't want to go for dermpath? I am starting to think so.

 

[pathdawg]

My limited exposure to cytology so far has been very unenlightening. I just don't like it, and don't find it interesting. Am I stuck with academics if I don't like either hemepath or cyto and I don't want to go for dermpath? I am starting to think so.

Cyto is like surgpath, just without the architecture. I think the more you learn about cyto, the more you'll like it.

 

[deschutes]

From my limited exposure, cytologists tend to be quite fanatical (and also very good) at what they do.

"I trust the cells better."

 

[yaah]

Cyto is like surgpath, just without the architecture. I think the more you learn about cyto, the more you'll like it.

I hope so. I hope that I can like enough to become decent at it, because it is a useful way to analyze things.

 

[pathdawg]

I hope so. I hope that I can like enough to become decent at it, because it is a useful way to analyze things.

For shizzle. Try to do touch/smear preps on all of your frozens and correlate them. That is a good way to learn cytology and have immediate surgpath correlation.

 

[pathdawg]

From my limited exposure, cytologists tend to be quite fanatical (and also very good) at what they do.

"I trust the cells better."

I think all specialists and subspecialists tend to be fairly "fanatical" about what they do, since its their name and reputation on the line.

btw, I 've noticed that hematopathologists are way more fanatical by nature. Must be all of those cluster differential numbers buzzing around in their heads.

 

[scopemonkey]

Dats why cytologists be poh, they dont realize immunos=$$$.

Smart cytologists plan for the possible immuno.
Cytology is high risk but I like the cheap thrill.

 

[Whisker Barrel Cortex]

As radiologists who do a lot of FNAs (thyroid, soft tissue nodules, abdominal masses, etc), we thank god when there is a good cyto guy on. We have them look at the sample while the patient is still on the table (set up in advance) in case we need more sample. Except for thyroids, the majority of the time we end up doing innumerable repeat passes or, if possible, core biopsies. The one exception is this one badass cytopathologist who will actually give us an answer without 50 passes or a core. Its gotten to the point that we don't even schedule FNAs on the days that the other pathologists are on.

 

[yaah]

As radiologists who do a lot of FNAs (thyroid, soft tissue nodules, abdominal masses, etc), we thank god when there is a good cyto guy on. We have them look at the sample while the patient is still on the table (set up in advance) in case we need more sample. Except for thyroids, the majority of the time we end up doing innumerable repeat passes or, if possible, core biopsies. The one exception is this one badass cytopathologist who will actually give us an answer without 50 passes or a core. Its gotten to the point that we don't even schedule FNAs on the days that the other pathologists are on.

What does he sign stuff out as though? Is he right? Problem with CT guided FNAs is that you just end up with blood and debris so much. I would like to be, if I end up doing cyto, someone who can make calls with confidence but if you are wrong, there can be major problems, and hedging is sometimes the only thing you can do.

 

[Brian Pavlovitz]

As radiologists who do a lot of FNAs (thyroid, soft tissue nodules, abdominal masses, etc), we thank god when there is a good cyto guy on. We have them look at the sample while the patient is still on the table (set up in advance) in case we need more sample. Except for thyroids, the majority of the time we end up doing innumerable repeat passes or, if possible, core biopsies. The one exception is this one badass cytopathologist who will actually give us an answer without 50 passes or a core. Its gotten to the point that we don't even schedule FNAs on the days that the other pathologists are on.

When I was a cytotech, we were the ones that actually went on these needles and gave the assessment--essentially saying 'you have enough specimen' or 'you need more'. I'd say that for a majority of the cases, it wasn't too difficult to tell whether or not it was malignant (of course, as techs we weren't allowed to tell them this...). In many cases, squamous vs. adeno wasn't even in question. There were those difficult cases, but we weren't there to give them a definite answer: that was for the cytopath fellow or the attending!

Still, it was nice to be able to work that closely (and independently) with the radiologists.

 

[DasN]

HI Brian Pavlovitz!!

 

[Mrbojangles]

I don't understand the point of cytology but then again I just had my first week of cyto. Pap smears make sense, but what is up with the FNAs? Most of the diagnoses I've seen comes from looking at the processing of the remaining needle tissue rather than the smear. Why even bother looking at the smear for signout, except when you're asked by the radiologist to come and see if their pass was diagnostic?

 

[deschutes]

Was told by one resident that cytology will get more important because of the push to do more with less.

Was told by another senior resident that cytology is going to go out the window

I haven't done any.

 

[A.D.O.R.]

Was told by one resident that cytology will get more important because of the push to do more with less.

Was told by another senior resident that cytology is going to go out the window

I haven't done any.

Do you think the cytopathology is on its last leg vs. thriving perspective is regional? I've been told that cytopath is pretty much dead back east but thriving in northern california. Don't have any knowledge about southern california.

 

[miko2005]

I am curious about job opprtunities after fellowship in hemepath??

 

[yaah]

Do you think the cytopathology is on its last leg vs. thriving perspective is regional? I've been told that cytopath is pretty much dead back east but thriving in northern california. Don't have any knowledge about southern california.

I think it may even vary from institution to institution. Different practices abound. Like here, the pulmonologists and surgeons INSIST on doing bronchoscopies with biopsy for attempted diagnosis of interstitial lung disease, which has a sensitivity of about 5%. The path attendings here say it is ingrained in the culture and they are somehow not swayed by the comments on about 95% of their transbronch biopsies "Tissue insufficient for diagnosis of interstitial lung disease."

At Wake Forest, they diagnose and treat many sarcomas based on FNA only, because one of the attendings there will make diagnoses on them. Breast FNAs are not done commonly here at all. And we almost never see sarcoma FNAs. I think perhaps the future will depend on availability of molecular tests for diagnosis, from tissue obtained by FNA. But who knows.

 

[cytoborg]

As radiologists who do a lot of FNAs (thyroid, soft tissue nodules, abdominal masses, etc), we thank god when there is a good cyto guy on. We have them look at the sample while the patient is still on the table (set up in advance) in case we need more sample. Except for thyroids, the majority of the time we end up doing innumerable repeat passes or, if possible, core biopsies. The one exception is this one badass cytopathologist who will actually give us an answer without 50 passes or a core. Its gotten to the point that we don't even schedule FNAs on the days that the other pathologists are on.

Funny, I thought it was the person with the needle who influences how many passes are needed. As I tell the surgeons, give us the right material, and we'll give you the right answer.

Seriously though, I enjoy FNA, whether done by us or radiology or ENT or whomever. On the other hand, I despise cervical cytology. I wonder if it's possible to do one without the other.

 

[cytoborg]

Do you think the cytopathology is on its last leg vs. thriving perspective is regional? I've been told that cytopath is pretty much dead back east but thriving in northern california. Don't have any knowledge about southern california.

Having done cytology rotations on both East and West coasts now, I have observed differences. The main difference is breast FNA, which is a highly controversial and political, not to mention litigious, area. At most of the major centers back East, it is just not done - the radiologists are doing cores - whereas lots of it is done here.

 

[Brian Pavlovitz]

Do you think the cytopathology is on its last leg vs. thriving perspective is regional? I've been told that cytopath is pretty much dead back east but thriving in northern california. Don't have any knowledge about southern california.

I guess it's all institution-dependent. We do a ton of FNA's (including pathologist or fellow-performed in clinic) at SUNY Upstate--especially Thyroid, CT-guided lung, and Endoscopic Ultrasound Guided of the pancreas. If the department has a good relationship with practitioners, they tend to rely more on the cytology to direct patient management. I think they have seen a decrease in the number of breast FNA's vs. cores; but in Rochester, breast FNA is alive and well.

I think the need for cervical cytology will certainly decrease thanks to the HPV vaccine, but we won't see a direct impact for at least 10 years. FNA will probably remain popular. One can argue "why not just get a core...?", but FNA is unique in that you can provide an answer on the spot. Besides, seeing patients in the FNA clinic is at least SOME justification for taking Step 2 CS!

 

[Mrbojangles]

I guess it's all institution-dependent. We do a ton of FNA's (including pathologist or fellow-performed in clinic) at SUNY Upstate--especially Thyroid, CT-guided lung, and Endoscopic Ultrasound Guided of the pancreas.

Are/were you a cytotech at Upstate? I never did a cytology elective as a student, but where was the cytotech screening room? But it is cool that the pathologists have their own cytology clinic.

 

[DarksideAllstar]

I don't understand the point of cytology but then again I just had my first week of cyto. Pap smears make sense, but what is up with the FNAs? Most of the diagnoses I've seen comes from looking at the processing of the remaining needle tissue rather than the smear. Why even bother looking at the smear for signout, except when you're asked by the radiologist to come and see if their pass was diagnostic?

Not all of the cases have cores (usually not too many if they are doing FNAs). A lot of our U/S-guided breast and thyroid FNAs were just 2-3 passes for slides, and sometimes an extra for cell-block (particularly if the spcimen is bloody). Usually we could make the diagnosis on smear alone. I think that the success of cytology is how adept you are with a needle. If you suck, chances are your smear isnt going to be diagnostic. It was nice working with faculty who are leaders in the field. Anyway, since doing a cyto elective I have a better appreciation of histopath and cytologic features of malignancy.

 

[DarksideAllstar]

I think neuropath might be worse. Try getting a job with those credentials. Its not like you can just go around stabbing a needle in people's brains everyday. I hear the only way to get a job in neuropath is if someone dies.

I hope this post has features of sarcasm that I am just not appreciating. I think neuropath would be a nice choice if you wanted to solely stay in academics at a tertiary center. I think neuro is pretty cool, but rather difficult once you go outside the realm of gliomas.

 

[cytoborg]

I think they have seen a decrease in the number of breast FNA's vs. cores; but in Rochester, breast FNA is alive and well.

Interesting to hear.

It seems like patients would prefer the FNA. That "needle" they use for the core is freaking huge!

 

[Brian Pavlovitz]

Are/were you a cytotech at Upstate? I never did a cytology elective as a student, but where was the cytotech screening room? But it is cool that the pathologists have their own cytology clinic.

I was there from '99-'00. The screening room is tucked away in the cytology sign out room across from the current residents room.

 

[Doctor B.]

Here's something to provoke some debate:

Should FNA's be done on lymph nodes? Or should they go straight to excisional biopsy?

In my limited experience (i.e.- as a resident), 90% of the node needles get signed out as: atypical lymphoid infiltrate, recommend excisional biopsy.

 

[pathdawg]

Here's something to provoke some debate:

Should FNA's be done on lymph nodes? Or should they go straight to excisional biopsy?

In my limited experience (i.e.- as a resident), 90% of the node needles get signed out as: atypical lymphoid infiltrate, recommend excisional biopsy.

Lymph nodes can and indeed should be fna'ed. I recommend submiiting a pass in rpmi for flow cytometry. The rest can go in cytolyte. Micro cultures can also be taken if needed.

The only caveat is the finding of a polymorphous population in an fna. Hodgkin's cannot usually be excluded.

 

[Doctor B.]

Lymph nodes can and indeed should be fna'ed. I recommend submiiting a pass in rpmi for flow cytometry. The rest can go in cytolyte. Micro cultures can also be taken if needed.

The only caveat is the finding of a polymorphous population in an fna. Hodgkin's cannot usually be excluded.

Why not go straight to biopsy though? Even with flow, it seems like more often than not, a definitive diagnosis is not rendered by cytology. Plus, in many cases, morphology is a key aspect of making the diagnosis.

FYI, just playing devil's advocate here.

 

[LADoc00]

Lymph nodes can and indeed should be fna'ed. I recommend submiiting a pass in rpmi for flow cytometry. The rest can go in cytolyte. Micro cultures can also be taken if needed.

The only caveat is the finding of a polymorphous population in an fna. Hodgkin's cannot usually be excluded.

Pathdawg, do you have in house flow capability? I think this makes a huge difference on your viability and false negative rate. My current station has no in house flow, we are sending it across town and the false negative rate is 50%, almost all the cases end up going to excisional biopsy+paraffin immunos because many things you cant resolve by flow anyway: Hodgkin's, L+H Hodgkin's, ALCL etc etc. Tho from the $ angle, flowing nodes can generate some impressive income.

 

[pathdawg]

Why not go straight to biopsy though? Even with flow, it seems like more often than not, a definitive diagnosis is not rendered by cytology. Plus, in many cases, morphology is a key aspect of making the diagnosis.

FYI, just playing devil's advocate here.

I think the main reason is that fna is so easy and non-invasive. Why take someone to the OR, deal with anaesthesia issues, cut them open, and deal with post-op complications when you can just needle a lesion? I understand your point if a lesion has to be taken out anyway, but fna can help avoid surgery (if done right and put together with the clinical picture).

 

[pathdawg]

Pathdawg, do you have in house flow capability? I think this makes a huge difference on your viability and false negative rate. My current station has no in house flow, we are sending it across town and the false negative rate is 50%, almost all the cases end up going to excisional biopsy+paraffin immunos because many things you cant resolve by flow anyway: Hodgkin's, L+H Hodgkin's, ALCL etc etc. Tho from the $ angle, flowing nodes can generate some impressive income.

We do not have in-house flow, and that sucks. But, in my experience, for most nhl's, rpmi keeps the cells viable for long enough to do flow. Granted, for high-grade lesions with rapid cell turnover, viability can definitely be a problem, but honestly, that issue doesn't come up too often.

 

[yaah]

Here we have in house flow as well, but the same thing happens. The only disease that is really treated based on flow only seems to be CLL, and that only when there is an absolute lymphocytosis and there is no high suspicion for mantle cell in leukemic phase.

I had this conversation with another resident yesterday. Both of us agreed that if we had an enlarged lymph node that needed biopsy we would refuse FNA and tell them to just go to excisional biopsy. FNA just seems to delay things more. Even if it is definitive clinicians still have enough suspicion in the results to warrant another biopsy. The only thing that FNA with flow seems to help on is when the FNA is read as suspicious and the flow gives an immunophenotype. When the biopsy comes out, and the histology is consistent with the immunophenotype, they will cancel the flow on the node biopsy and do fewer immunostains. But that isn't saving resources at all because they were done on the FNA.

We also had a visiting prof who diagnosis sarcomas on FNA. As a patient, I would be saying "hell no."

FNA seems useful in the following situations (to me)

1) Enlarged accessible node in a patient with a history of prior malignancy and suspected new met.

2) Cystic lesion.

Thyroid FNA seems a waste. The algorithm seems to go:

A) "Follicular neoplasm" - patient goes to surgery with possible frozen section

B) "Suspicious for papillary cancer" or even "Papillary cancer" (or medullary) - patient goes to surgery and they usually do frozen section anyway for some reason.

c) Colloid and follicular cells - patient goes to surgery if the nodule doesn't go away.

Same with parotid FNAs.

 

[pathdawg]

Thyroid FNA seems a waste. The algorithm seems to go:

A) "Follicular neoplasm" - patient goes to surgery with possible frozen section

B) "Suspicious for papillary cancer" or even "Papillary cancer" (or medullary) - patient goes to surgery and they usually do frozen section anyway for some reason.

c) Colloid and follicular cells - patient goes to surgery if the nodule doesn't go away.

Same with parotid FNAs.

I have to clarify a few things here. My cytology spidey-senses are going nuts.

Thyroid fna's are standard of care for triaging which cases go to surgery. You made a few points that are inaccurate.

A) The diagnosis of follicular neoplasm by fna precludes the need for frozen section. The gland has to come out in order to differentiate follicular adenoma from carcinoma. This distinction cannot (I repeat CANNOT) be made on fs. The entire capsule must be submitted (on permanents) in order to search for capsular or vascular invasion. Actual harm can be done by doing a frozen on a follicular lesion, since sectioning a follicular carcinoma nodule before the gland can be fixed in formulin can cause the capsule to retract, thus rendering the correct diagnosis much more difficult (or perhaps impossible).

B) A positive fna for papillary ca also precludes the need for fs. The sensitivity and specificity for this dx on fna is very high. No confirmatory fs needed.

C) I assume by colloid and follicular cells you mean a nodular goiter. Patients only go for surgery is the lesion causes symptomatology. Surgery is not warranted simply because the lesion doesn't go away.

There. I feel much better now.

 

[Mrbojangles]

The gland has to come out in order to differentiate follicular adenoma from carcinoma. This distinction cannot (I repeat CANNOT) be made on fs. The entire capsule must be submitted (on permanents) in order to search for capsular or vascular invasion. Actual harm can be done by doing a frozen on a follicular lesion, since sectioning a follicular carcinoma nodule before the gland can be fixed in formulin can cause the capsule to retract, thus rendering the correct diagnosis much more difficult (or perhaps impossible).

Say you actually see capsular invasion on frozen section. Will that actually change what the surgeon does? Like will he sample cervical nodes lateral to the IJV?

nodular goiter. Patients only go for surgery is the lesion causes symptomatology. Surgery is not warranted simply because the lesion doesn't go away.

I think that is a regional, institutional, or surgeon dependent thing. One surgeon will schedule total thyroidectomies after an FNA that is c/w colloid goiter.

 

[pathdawg]

Say you actually see capsular invasion on frozen section. Will that actually change what the surgeon does? Like will he sample cervical nodes lateral to the IJV?

I think that is a regional, institutional, or surgeon dependent thing. One surgeon will schedule total thyroidectomies after an FNA that is c/w colloid goiter.

The odds of finding capsular invasion on fs are virtually nill. Think about it. If you have a large follicular lesion with only focal capsular invasion (a difficult enough diagnosis on permanent section), the chances of sampling the right area (in addition to dealing with frozen section artifact), are incredibly poor. I have never seen a follicular carcinoma diagnosed on frozen. The reason for this is that is would be malpractice. The only correct diagnosis for a folicular lesion at frozen section is: Follicular lesion. Defer to permanent sections.

Lymph nodes are generally not sampled for follicular carcinoma, because these tumors characteristically invade through blood vessels (or direct extension). Papillary CA typically invades lymphactics. Again, this underscores the importance of fna, since the fna results would determine the need for lymph node sampling.


It is a surgeon-dependent issue. You've got some aggressive surgeons over there. A goiter going directly to total thyroidectomy. Yikes. A thyroidectomy is far from a benign procedure. Lots of potential complications.

 

[yaah]

OK - this is not meant to be an attack on you or a slam in anyway, but this is the truth in what I have seen in med school and here on occasion!

Thyroid fna's are standard of care for triaging which cases go to surgery.

I only wish that were true.

A) The diagnosis of follicular neoplasm by fna precludes the need for frozen section. The gland has to come out in order to differentiate follicular adenoma from carcinoma. This distinction cannot (I repeat CANNOT) be made on fs. The entire capsule must be submitted (on permanents) in order to search for capsular or vascular invasion. Actual harm can be done by doing a frozen on a follicular lesion, since sectioning a follicular carcinoma nodule before the gland can be fixed in formulin can cause the capsule to retract, thus rendering the correct diagnosis much more difficult (or perhaps impossible).

Yeah, I know.

They tell this to the surgeons almost every time, and at every conference. Does it matter? It seems not to. I wish I was joking. There are some surgeons who seem to do a frozen on EVERY thyroid that comes out.

B) A positive fna for papillary ca also precludes the need for fs. The sensitivity and specificity for this dx on fna is very high. No confirmatory fs needed.

Again, I don't disagree with you.

C) I assume by colloid and follicular cells you mean a nodular goiter. Patients only go for surgery is the lesion causes symptomatology. Surgery is not warranted simply because the lesion doesn't go away.

What if one of those lesions is a follicular carcinoma? Better operate with frozen section!

There. I feel much better now.

I agreed with everything you said. Too bad it doesn't happen that way a lot of the time.

 

[AngryTesticle]

OK - this is not meant to be an attack on you or a slam in anyway, but this is the truth in what I have seen in med school and here on occasion!



I only wish that were true.



Yeah, I know.

They tell this to the surgeons almost every time, and at every conference. Does it matter? It seems not to. I wish I was joking. There are some surgeons who seem to do a frozen on EVERY thyroid that comes out.


Again, I don't disagree with you.




What if one of those lesions is a follicular carcinoma? Better operate with frozen section!



I agreed with everything you said. Too bad it doesn't happen that way a lot of the time.

Interesting discussion. Here, we typically don't do frozens on thyroids and FNA results to dictate the need for thyroidectomies. But I can appreciate regional and surgeon-to-surgeon differences as to "standard" practices of thyroid frozens or other kinds of cases for that matter.

We do get some "inappropriate" frozens. But that is sometimes a subjective assessment. Remember, in principle, frozen sections are to be done IF the results will have impact on further surgical management DURING the case in question.

 

[pathdawg]

OK - this is not meant to be an attack on you or a slam in anyway, but this is the truth in what I have seen in med school and here on occasion!



I only wish that were true.



Yeah, I know.

They tell this to the surgeons almost every time, and at every conference. Does it matter? It seems not to. I wish I was joking. There are some surgeons who seem to do a frozen on EVERY thyroid that comes out.


Again, I don't disagree with you.




What if one of those lesions is a follicular carcinoma? Better operate with frozen section!



I agreed with everything you said. Too bad it doesn't happen that way a lot of the time.

I hear what you are saying. I think our role as pathologists is to educate surgeons. Nobody realized more than I the incessant stubornness of our surgery bretheran. While I try to pick my battles with them, I am not eager to practice under the standard of care just to make some surgeon bully happy.

Most surgeons who insist on unnessesary frozens are coming from a very ignorant point of view. We should (delicately) discourage them in order to protect each other.

 

[yaah]

Most surgeons who insist on unnessesary frozens are coming from a very ignorant point of view. We should (delicately) discourage them in order to protect each other.

Yeah, I always admire attendings (or fellows sometimes) who get the specimen and call in and ask why they need the frozen and how it is going to change the procedure. At least it makes them think a bit.

 

[cytoborg]

Yeah, I always admire attendings (or fellows sometimes) who get the specimen and call in and ask why they need the frozen and how it is going to change the procedure. At least it makes them think a bit.

I've been called ballsy (crazy?) for doing that, but it drives me up the wall when they don't THINK about why they need the frozen, and I savor the opportunity to educate them. Sometimes when I'm feeling a little chicken, I pretend I'm asking for my own enlightenment, or I just give them a little FYI for next time, or I pretend I'm watching out for their best interests by "just making sure you maximize your chances of getting a correct diagnosis, which is more easily done on permanent sections."