Taking Steps To Get A Better Look
Having just sent a surgical specimen to pathology, gynecologic cancer surgeon Andrew Berchuck, MD, pauses to call pathologist Shannon McCall, MD, to get her assessment before proceeding further. As she goes into detail about the frozen section projected on her screen, he interrupts, “I’ll be right there.”
When a cancer patient has surgery, with few exceptions, their resected tissue is automatically sent to pathology and a report generated days later describing what was found. That’s the standard-of-care. But in about half of all surgeries performed each day at Duke, a real-time pathological analysis may also be performed on a “frozen section” of the resected tissue — before the patient wakes up.
“I’m definitely a surgeon who wants to get as much information as possible via an in-person interaction with the pathologist to best assure that we do the right thing for the patient while they’re still asleep,” said Berchuck, going on to explain, with a colorful metaphor, how this real-time collaboration is crucial, for him, in certain cases. “Can you imagine two art critics talking about a Picasso painting on the phone, with the one who has looked at it relaying her interpretation to the other who hasn’t seen it? It’s so much better if they both look at it. There’s so much subtlety, so much visual that goes beyond words. The surgeon staying in the OR and getting a verbal report from the pathologist just isn’t quite the same as walking 30 steps from the operating room to the Surgical Pathology Lab for a face-to-face interaction.”
Frozen sections are most common in lung, gynecologic, and genitourinary cancers but are also often performed in breast and head and neck cancers. They’re requested by the surgeon in situations where those findings could change the immediate surgical management of the case. For example, this could be to confirm (or deny) a suspicion of cancer, to make certain that surgeons have gotten a good margin for resection on cancers that have already been confirmed, or to assess the extent of local spread or distant metastasis. Frozen sections are often performed on the sentinel lymph node(s) — the first lymph node to which cancer cells are most likely to spread from a primary tumor.
“This method is very labor intensive and doesn’t have the best histology, but it’s done when a surgeon needs immediate results,” explained McCall, who directs the BioRepository and Precision Pathology Center shared resource and subspecializes in gastrointestinal cancer pathology. “I like to analyze and have a minute to think about what I’m seeing and determine if there’s anything we should be testing for or anything we’re missing; to be able to look at it with different people and make sure that when we generate the report, it’s the right one for our patients.”
Berchuck gave some examples of how a frozen section can also provide real-time guidance for surgical next steps.
“In uterine cancer, we remove the uterus, tubes and ovaries and send them to the pathologist. The grade of the cancer and the depth of invasion into the uterine wall, and other factors might determine the extent of lymph node staging that we do,” he said. “While these days we tend to inject dye and remove sentinel nodes from all of these patients, if one side doesn’t map or if there’s extensive cancer there we could go back and do a full node dissection on that side where it didn’t map. But if the frozen section shows that the cancer was very small or not invading the uterine wall we might not. Same thing goes for whether we sample higher nodes in the aortic area.”
Frozen sections are also performed with nearly every endometrial cancer case, he said, as well as to assess whether ovarian masses are benign, cancerous, or suspicious and determine grade or histologic type in already known-to-be-cancerous masses.
“Dr. Berchuck has very much reached across the aisle into pathology; he’s a known face in the pathology department, as is Dr. Tong,” said McCall. “We do of course also have mechanisms for (post-op) collaboration — at the weekly tumor board meetings that pathologists, surgeons and oncologists attend.”
Thoracic cancer surgeon Betty Tong, MD, said she likes to walk over to pathology rather than take a phone call to learn the results of the frozen sections she requests for lung nodules (radiographically suspicious, but not confirmed as cancerous before surgery), “more out of curiosity than anything.” But there are also uncommon cases for which she said she needs to be in the room with the pathologist.
“In certain scenarios it’s exquisitely helpful to be able to walk down the hall and look at the specimen with the pathologist and point to the exact area I’m most worried about; the area that’s a little bit suspicious,” said Tong. “It’s all about being on the same page. I think it’s always better when people have a shared mental model and being there (in the room) helps for us to engage in that model. It’s a good mental break for me as well, to be able to walk out of the room and change my focus for a few minutes.”
Urologic surgeon Michael Ferrandino, MD, estimates that he orders a frozen section probably once a month and needs to go to the surgery pathology lab mid-surgery to review frozens a few times a year.
"When the tissue does not appear or move as expected and I know I am in the right planes, going to the lab can help clarify things," Ferrandino said. "It helps to see at the microscopic level, with the pathologist, what I can't see with the naked eye."
Nearly all academic centers have a surgery pathology lab in close proximity to the operating rooms, unlike smaller community hospitals. At Duke, it’s in the Duke Medical Pavilion (DMP) across from the nurses’ station. (The main pathology lab, meanwhile, where specimens undergo final processing, is located in another building)
“It’s a good thing to have your pathology suite near the operating rooms,” said McCall. “Some institutions say they’re building new operating rooms and that there’s no room for pathology, so they’ll put pathology in another building and use runners. Pathologists would never see the surgeon if that happened. I think the kind of collaboration we have at Duke is a testament to how much and how well we work together.”