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Frozen Section Pathology for Decision Making in Parotid Surgery

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Frozen Section Pathology for Decision Making in Parotid Surgery Research Original Investigation Frozen Section Pathology for Decision Making in Parotid Surgery Kerry D. Olsen, MD; Eric J. Moore, MD; Jean E. Lewis, MD IMPORTANCE For parotid lesions, the high accuracy and utility of intraoperative frozen section (FS) pathology, compared with permanent section pathology, facilitates intraoperative decision making about the extent of surgery required. OBJECTIVE To demonstrate the accuracy and utility of FS pathology of parotid lesions as one factor in intraoperative decision making. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of patients undergoing parotidectomy at a tertiary care center. INTERVENTIONS Evaluation of the accuracy of FS pathology for parotid surgery by comparing FS pathology results with those of permanent section. MAIN OUTCOMES AND MEASURES Documented changes from FS to permanent section in 1339 parotidectomy pathology reports conducted from January 1, 2000, through December 31, 2009, included 693 benign and 268 primary and metastatic malignant tumors. RESULTS Changes in diagnosis were found from benign to malignant (n = 11) and malignant to benign (n = 2). Sensitivity and specificity of a malignant diagnosis were 98.5% and 99.0%, respectively. Other changes were for lymphoma vs inflammation or lymphoma typing (n = 89) and for confirmation of or change in tumor type for benign (n = 36) or malignant (n = 69) tumors. No case changed from low- to high-grade malignant tumor. Only 4 cases that changed from FS to permanent section would have affected intraoperative decision making. Three patients underwent additional surgery 2 to 3 weeks later. Overall, only 1 Author Affiliations: Department of patient was overtreated (lymphoma initially deemed carcinoma). Otorhinolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota (Olsen, Moore); Division CONCLUSIONS AND RELEVANCE Frozen section pathology for parotid lesions has high of Anatomic Pathology, Mayo Clinic, accuracy and utility in intraoperative decision making, facilitating timely complete Rochester, Minnesota (Lewis). procedures. Corresponding Author: Kerry D. Olsen, MD, Department of Otorhinolaryngology–Head and Neck JAMA Otolaryngol Head Neck Surg. 2013;139(12):1275-1278. doi:10.1001/jamaoto.2013.5217 Surgery, Mayo Clinic, 200 First St SW, Published online October 17, 2013. Rochester, MN 55905 (olsen.kerry @mayo.edu). arotid neoplasms are uncommon tumors that present Many centers use preoperative FNA cytology to aid in di- unique challenges in diagnosis and effective treat- agnosis and management decision making. However, FNA cy- P ment planning. The patient’s history, examination find- tology of salivary gland lesions has a high false-negative rate ings, and imaging all contribute to an overall clinical assess- that limits its usefulness, so few surgeons are willing to com- ment. Operative decision making, including the amount of mit to a comprehensive or extended surgical procedure on the gland removed (partial, superficial, deep, or total), facial nerve result of this test alone. Physicians may use FNA cytology for resection (partial or total), and removal of parotid and re- an initial impression and delay any decisions on major sur- gional cervical nodes, is generally based on clinical and sur- gery or other treatment until permanent section pathology is gical findings, imaging results, and the pathologic diagnosis available. from fine-needle aspiration (FNA) cytology, frozen section (FS) Some medical centers also use FS pathology for parotid pa- pathology, or permanent section pathology (standard hema- thology and margin analysis. However, many pathologists do toxylin-eosin–stained sections). Accurate pathologic diagno- not because of the rarity of these neoplasms, the variety of tu- sis is challenging because of the rarity and variety of parotid mors, and the challenges in making an accurate diagnosis from tumors. FS pathology. Prior authors evaluating the value of FS pathol- jamaotolaryngology.com JAMA Otolaryngology–Head & Neck Surgery December 2013 Volume 139, Number 12 1275 Copyright 2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Research Original Investigation Frozen Section Pathology ogy have determined that it offers greater accuracy and more and pathologic findings are all used to guide intraoperative and improved sensitivity than FNA cytology. Most studies, though, postoperative management. have examined only the accuracy of FS pathology in deter- mining benign vs malignant disease and margin extent.1 At our institution, FNA cytology is rarely performed for pa- Methods rotid lesions. Instead, we rely on FS pathology to provide his- topathologic intraoperative information to guide surgical man- Frozen section analysis of nearly all surgical specimens is stan- agement. The surgeon needs to know not only whether the dard practice at our institution. Approximately 20 patholo- tumor is benign or malignant but also whether it is lym- gists with general expertise participate in the FS laboratory. In phoma or carcinoma, whether it is low grade or high grade, the most cases, a final report is generated on the basis of the FS status of any intraparotid and extraparotid lymph nodes, and pathology result. However, in more complex cases, such as the margin analysis. The extent of parotid and neck surgery is those requiring immunostains and/or intradepartmental con- influenced by pathologic information. Operative surgical de- sultation, a preliminary FS report is issued, and the final re- cisions include whether a partial, superficial, deep, or total pa- port is deferred to permanent section. For every FS proce- rotidectomy should be performed. Margin analysis of an in- dure performed, a corresponding hematoxylin-eosin section volved nerve or adjacent structures also factors into the extent is prepared and reviewed the following day. of an operation. Finally, a decision regarding the removal of Approval from the Mayo Clinic Institutional Review Board regional neck nodes and deep lobe parotid nodes can be guided was obtained to review all FS and permanent section pathol- by the parotid tumor histology and/or involvement of the nodes ogy reports for all cases of parotid gland surgery in patients in the superficial lobe. Frozen section pathology can help in who had given written permission for the use of their medi- all of these decision points, especially the last one. cal records for research purposes. Any change in diagnosis on If FS pathology provides reliable information, patients the permanent section pathology report was noted, even if a could benefit by receiving all surgical procedures in a single preliminary FS pathology report stated that the diagnosis was operation. There would be no need to return later to the op- suspect or suspicious, and it was then confirmed on perma- erating room for an operation the surgeon would have per- nent section. When there was any change in the final pathol- formed if the correct diagnosis had been known at the time of ogy report, we reviewed it to determine whether the change the initial surgery or to rely instead on radiation therapy post- led to overtreatment or undertreatment surgically. All appli- operatively. Accurate FS pathology can provide the surgeon cable surgical records were then reviewed. with an important factor in planning a rational oncologic pro- cedure that is based on knowledge of tumor behavior. However, if the information from FS parotid pathology is Results not accurate, it may increase the potential for performing the wrong operation and possibly harming the patient. The pa- During a 10-year period from January 1, 2000, through Decem- tient may undergo unnecessary surgery, return for another op- ber 31, 2009, a total of 1339 parotid surgical procedures were eration, or accept a nonsurgical treatment because surgeons conducted at Mayo Clinic, Rochester, Minnesota, with FS analy- may be reluctant to operate again in a parotid bed after prior sis performed on each case. Subsequent pathologic review led parotid surgery. to a permanent pathologic diagnosis for each case. There were For the patient with a parotid mass, we use FS evaluation 693 benign tumors and 268 primary and metastatic malig- of the lesion as a key factor to determine whether to proceed nant lesions. The remaining 378 cases included infections, si- with deep lobe removal or neck dissection during the initial aladenitis, and inflammatory nodes. operation. Frozen section pathology has been used for sev- No change was found in the pathology report from FS to eral decades in all parotid operations at Mayo Clinic. This in- permanent section in 1119 of the 1339 cases of parotid surgery traoperative diagnostic approach has potential value for our that underwent the FS procedure. The remaining 220 cases patients. If accurate, it could be cost-effective if it eliminated were studied in detail. The change from FS to permanent sec- the need for FNA, additional surgery, or radiotherapy. tion included both those cases for which the diagnosis was pre- This report is the largest series to date evaluating the ac- liminary and confirmed on permanent section and those cases curacy of FS pathology for parotid surgery. We sought to de- that were indeterminate or that had any substantive change termine whether the FS diagnosis of the pathologist, as con- made in diagnosis from FS to permanent section (Table). veyed to the surgeon, provided information that led to Of the 220 cases, 89 were suggestive of lymphoma or an overtreatment
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