Frozen Section Service is covered during both the Surgical Pathology and Autopsy rotations.
Integrated Training at NIH includes:
Refer to the section on integrated training for more details.
Fund of Medical Knowledge
The resident will develop general medical and pathology knowledge relevant to the practice of pathology. This will include an understanding of basic concepts of disease; the pathophysiology of common disorders; the epidemiologic, clinical, morphologic, biochemical, and/or molecular genetic features of common disorders; the prognostic and general therapeutic implications of common disease states; and the societal impact and preventative aspects of common diseases.
Application of Medical Knowledge in the Practice of Pathology
The resident will learn to effectively apply the acquired medical knowledge in the day-to-day practice of pathology in diagnosis, prognosis, differential diagnosis,and therapeutic options.
Practice-Based Learning and Improvement
Evidence-Based Practice
The resident will participate in conferences, other educational activities and private reading of pertinent pathology material to develop the skills necessary for the development and resolution of a differential diagnosis. The resident must develop the ability to critically evaluate the quality of research studies pertinent to diagnosis and other medical decisions.
Use of Information Technology
The resident will learn to use information technologies to improve the day-to-day practice of pathology.
Interpersonal and Communication Skills
Communication Skills
The resident will learn to communicate effectively and courteously with health care providers, laboratory staff members, administrators, patients, and other individuals. These communications will include verbal and written formats. The resident must strive to communicate in a clear, concise, accurate, and appropriately focused manner.
Teamwork
The resident will learn to work as an effective member of the health care team in the course of the daily practice.
The resident must strive to perform all tasks in a responsible and timely fashion, facilitate the tasks of other team members, and be cooperative in the interactions with team members.
Professionalism
Courtesy and Collegiality
The resident must treat health care providers (including clinicians, nurses, other pathologists, technologists, transcriptionists, etc.), administrators, patients, and others courteously and respectfully.
Professional Responsibility
The resident will take the professional responsibilities seriously and act accordingly. The resident's professional responsibilities include clinical service, teaching, administrative tasks, research, institutional tasks, and work with professional organizations.
Systems-Based Practice
The Health Care System and the Role of Pathology
The resident must acquire knowledge of practice and health care delivery systems and an awareness of the role of pathology in the context of the greater health care system.
The resident will develop a working knowledge of different inpatient and outpatient delivery systems and the general regulatory and financial aspects of health care delivery.
The resident must learn the importance of providing effective and timely consultation to clinicians, advising health care providers in the provision of cost-effective care, while cognizant and in accord with patient privacy and confidentiality.
The resident should learn to provide coding, statistical and other relevant data, as needed in support of quality care and the Institution.
General Laboratory Administration
The resident will develop an understanding of the general administrative aspects of pathology practice.
The resident will learn to understand and apply the principles of quality control and quality management.
The resident will develop a working knowledge of laboratory staffing, laboratory instrumentation, workflow, turnaround time management, safety, customer service, regulatory accreditation, budget, and billing practices.
The resident is instructed by staff pathologists in the principles of gross description and diagnosis. He/she performs the gross examination of all surgical specimens and, after an initial period of instruction by the staff, prepares a gross description on his/her own. The gross description is reviewed with the staff at the time of sign-out.
The resident examines all surgical specimens microscopically and prepares a microscopic description. The resident is also expected to formulate a diagnosis based on gross and microscopic features, as well as clinical history. At sign-out, resident and staff review the case using a double-headed microscope; the gross and microscopic descriptions are reviewed by the staff pathologist, and necessary revisions are made.
The resident is instructed in the procedures involved in rapid frozen sections and is expected to become proficient in preparing and staining frozen sections. The resident reviews microscopic features and formulates a provisional diagnosis. After review of the frozen section material with the staff pathologist, a Surgical Pathology Consultation is entered in the chart and co-signed by the resident and staff pathologist. During the third year of training, depending on individual ability, the resident may be given sole responsibility for frozen section diagnosis. Staff supervision is always available.
At the third-year level, the residents assume more independent responsibility for surgical pathology diagnosis. The third-year resident is the first to review the histology on all biopsies. After making a preliminary diagnostic decision, the third-year resident reviews critical cases with the in-house staff pathologist and communicates with the clinician who submitted the case. The third-year resident also assists and instructs junior residents in the blocking of specimens and signing out of all surgical pathology cases. The importance of using clinical information to arrive at a correct diagnosis is emphasized in our program. The third-year residents are expected to play a major role in communicating with clinical staff.
The Surgical Pathology service is covered by two residents, a "Hot Seat" resident (or Chief Resident), and two staff members. See the tables below for delineation of responsibilities.
| Position | Duties |
|---|---|
"In-house" resident | Rush and small biopsies, routine specimens |
"In-house" staff | Frozen sections in PM, biopsies, routine specimens |
Autopsy resident | Covers frozen sections in the afternoon |
"Hot Seat" resident | Provisional diagnosis on all biopsies, instruction of and assistance to in-house resident. Assists physicians from other departments and reviews cases with them. Assists in tissue procurement. |
Resident | Frozen Sections in AM, submitted surgical specimens |
Staff | Frozen sections in AM, submitted surgical specimens. Assist with interdepartmental conferences. |
The resident on "in-house surgicals" and the senior staff on "in-house surgicals" are responsible for working up and rendering diagnoses on the surgical specimens.
The resident and staff provide intraoperative consults to the Surgery Branch, NCI, and the Surgical Neurology Branch, NINCDS, in the operating suites located in the ACRF. Each working day until 12:00 noon, the frozen sections are to be covered by the resident and staff on the submitted service, thereby freeing up the in-house resident and staff to sign out the in-house cases.
The resident is responsible for cutting, staining, and mounting the frozen section under the supervision of the staff. Touch preparations (fixed and stained with H&E, or air dried and stained with Diff Quick's stain) may provide additional diagnostic information. Check for previous material and, if pertinent, have it available at the time of the frozen section.
After a diagnosis or recommendation is made, the consult is recorded on the Consultation Form (SF 513). Complete the original and one carbon of the Consultation Form and make sure that the patient's full name and medical record number are on the form. The forms are signed by the staff and resident, and the original is filed in the patient's chart. The carbon is kept and filed with the final report. The information also should be incorporated into the final surgical pathology report. The consultation report should contain a brief description of the specimen on which the frozen section was performed and the interpretation rendered to the surgeon.
Make sure the frozen block is wrapped carefully in tissue paper (if small), put in fixative and submitted for histology. Frozen section blocks are given a specimen number followed by "FS", followed by the consecutive frozen section number for that specimen. For example, if specimen number 5 has 2 frozen sections, the blocks would be numbered "5SF1" and "5FS2". Record the specimen number and description on the Consultation Form. The actual frozen sections are saved with the case as a permanent record.
If the frozen section shows a tumor of uncertain histogenesis, another block of tissue should be frozen for immunocytochemistry. If tissue is sparse, the block used for the frozen section should not be fixed but kept frozen for immunocytochemical staining. Additional sections may be cut immediately for immunohistochemical staining. Tissue should also be submitted in 3% glutaraldehyde for electron microscopy.
The resident is responsible for overseeing the maintenance of the equipment and the materials needed in the frozen section room. Advise the Histopathology staff of needed supplies and equipment. Indications for frozen sections:
Location and Maintenance of the Frozen Section Room
The frozen section room is currently located adjacent to the operating room suites (2C533). There are two cryostats: either or both may be used. There is also a cryostat and stain set-up in both the autopsy room and the histology room. These areas are maintained and supervised by Histopathology staff and any questions regarding necessary supplies should be directed to them.
It is the responsibility of the resident on surgicals to ensure that the machine should be cutting properly, the stains are fresh and working, and the microscope is in good working order. The frozen section room should be checked at either the beginning or end of each week so that proper frozen sections are prepared during the week. Any problems should be communicated to the Histology Laboratory promptly.
WHEN THE TISSUE IS FRESH, THINK:
Division of Specimens
A large number of specimens are divided immediately after surgery so that portions of tissue can be used by different research programs. As a rule, specimens are divided in the blocking room (2A22) and a resident (and "Hot Seat" or staff) should respond to the call as soon as it is received. A tissue procurement nurse in charge of distributing the specimen will transport it from the operating room (OR) and take charge of the distribution.
MAKE SURE THERE IS ENOUGH TISSUE TO ESTABLISH THE DIAGNOSIS AND EVALUATE THE SPECIMEN (e.g., DO NOT GIVE AWAY MARGINS). REFER TO MANUAL OF INSTRUCTIONS FOR BLOCKING TECHNIQUES OF VARIOUS SPECIMENS. IN CASE OF DOUBT ASK FOR HELP.
Intake of Specimens
The specimens that are in the laboratory are grossed as soon as possible during the day with the assistance of one histology technician. The resident should go over the specimens and decide which are "small biopsies" and "large biopsies" and which are "routines." The classification of each specimen should be indicated on the blocking log sheet.
"Small biopsies" that are fixed are processed overnight and ready next day by 12:00 noon or 1:00 PM. The "large biopsies" are fixed for 24 hours before processing. Provisional diagnoses are made by the "hot seat" fellow. If the biopsy is received in saline, discard the fluid before adding formalin, otherwise the biopsies will not be fixed properly.
"Routines" are handled with second priority. See the GROSS ROOM PROCEDURES. Remember, a diagnosis cannot be made unless the tissue is ADEQUATELY FIXED. A 24-HOUR WAIT IS LESS TRAUMATIC TO THE PATIENT, THE SURGEON, AND THE PATHOLOGIST THAN IS A SECOND BIOPSY.
If finished blocking before 3:00 PM, the resident should "sweep" the laboratory for other biopsies and specimens. Gross specimens should be photographed.
Dictation completed by 4:00 PM will be transcribed the same day.
Surgical Specimens Requiring Decalcification
A bone biopsy in which the bone itself represents part of the diagnostic material will not be signed out until all decal sections are processed. Regardless of the findings in soft tissue, the case will be held until the decal specimens are processed. Only those cases in which the bone specimen is an incidental procedure not of diagnostic relevance will be signed out without decal specimens. For example, a thoracotomy specimen, which includes a rib removed incidentally as part of the procedure, may be signed out prior to processing of the rib biopsy if the rib showed no gross pathologic abnormality. Ribs are examined grossly only, unless otherwise specified.
After decalcification, residents will block all surgical specimens and submit them for histologic sections. Surgical specimens will not be blocked by the Histopathology Laboratory staff under any circumstances.
A log will be maintained in the surgical pathology blocking room to follow all surgical specimens requiring decalcification. Bone specimens undergoing decalcification will be checked on a daily basis, and decal solutions will be changed on a daily basis. The log will also contain the following information:
Routine decal solution (formic acid) and other rapid decal solutions destroy enzymatic activity, particularly chloro-acetate esterase reactivity in neutrophils and mast cells. When enzymatic activity is of importance in evaluating a specimen, alternative decal solutions should be used. EDTA is currently available and will preserve enzymatic activity. Touch preps may also be prepared from bone biopsies, and these are often suitable for cytochemical reactions.
Work-up of the Case and Sign-out
Screening for Surgical Case Review Committee
Cases may be considered for possible referral to the Surgical Case Review Committee, based on criteria (see Appendix A9) requiring referral. If a case meets a criterion for committee review, alert Dr. Armando Filie and complete a referral form.
Dictation Guidelines for Transcription
GROSS – Dictation of gross reports is to be done on the hands-free Lanier unit located in the specimen room near the operating room (OR). Depress ON/OFF button, enter assigned dictation number, and give needed information in the following order:
MICROSCOPIC – Dictation of microscopic reports is to be done using telephone call-in dictation lines (Speed Dial: 4-2828). Dial recorder number, enter assigned dictation number, and report type. Use 3 to reverse, 1 to listen, 4 to pause, and 2 to resume dictation. When finished with dictation, press 9 and hang up the telephone. These numbers can be accessed at any time, as often as needed--phones should not be left unattended, as recorders are voice activated. If changes are needed in gross, they should be indicated at the time of microscopic dictation.
When dictating microscopic reports, give needed information in the following order:
If you need to speak directly with the Transcription Office, you may reach them at 496-1838. You may call if you are having problems with the equipment or need to discuss a dictation.
Appendix C8 contains a reprint that discusses standards for the surgical pathology report. Please read these standards carefully and ensure that your reports meet them. Pay particular attention to the sections pertaining to gross and microscopic descriptions, and the final diagnosis.
Signing Reports
The transcriptionists complete reports within 4 hours. Before the reports are verified and released, the reports need to be carefully proofed and signed by the resident and the staff. The resident should edit the reports using the SoftPath™ LIS system before giving the reports to the staff for approval of signatures. MAKE SURE YOU SIGN THE REPORTS BEFORE 3:00 PM, AND THAT THEY ARE ACCURATE.
Reports Erroneously Issued Under an Incorrect Name or Requisition
The following procedures are required if a pathology report is inadvertently issued under an incorrect name:
Supplemental and Revised Reports
Both have different advantages and disadvantages, and should be used in different circumstances.
The Supplemental may be used to provide additional information that does not change the original diagnosis. The supplemental also can be used to add a brief comment to a previously verified report (e.g., special stains for organisms are negative).
If you wish to change or add a diagnosis, this should be done only in the form of a Revised Report.
The Supplemental or Revised report should be distributed to all individuals who received the original report.
The Revised reports and Supplemental reports will be filed with all previous reports.
Fixation and Handling of Surgical Specimens After Regular Working Hours
Specimens from the nursing units or clinics obtained after working hours at night or on weekends will be delivered to the receiving area outside the Histology Laboratory (2A22).
Those specimens should be delivered in fixative.
In order to ensure optimal preservation and fixation of those surgical specimens that are obtained after regular working hours, we suggest that, in all such cases, the OR contact the pathology resident on-call (through paging, 496-1211) and provide the resident with basic information about the case (diagnosis, type of surgery). This will enable the resident to begin to make an informed decision about how to best handle the tissue.
Final decisions may require discussion with the clinician and/or review of previous pathologic material. Possible options include the following:
If you receive duplicate material on a case that is signed out under another S#, issue a report referring to that NIH S# in the diagnostic line.
Additional material (stained slides, blocks) received before the case has been signed out should be given to Surgical Pathology office staff. List patient's name and current NIH S#.
Additional material received after the case is signed out, but from the same specimen (not a new biopsy on same patient), should be logged in with a request for a supplemental report. Use same S# as original case, and forward to Histology.
If you receive multiple blocks (> 5), you should try to select particular blocks to be recut for special stains, etc., after consultation with staff.
Once the additional material has been accessioned, you may enter a request for special studies in the SoftPath LIS.
Proof report carefully before signing it.
The resident on "submitted" surgicals is responsible for working up all the referred cases with the staff member on submitted service.
The material accessioned in the laboratory should include a complete tissue examination form filled out by the NIH clinician. It is essential that an accompanying pathology report or other document verifying that the slides submitted belong to the patient in question be available. In addition, the material may include slides, blocks, and wet tissue. When blocks are received, it is customary to prepare our own slides. Make sure that the outside code on the slide label is also on the NIH label.
As soon as you get the case from the Histology Laboratory, do a work-up and decide if more sections are needed or if you have to request the blocks from the referring hospital. When you receive blocks you have requested, submit it as additional material (see above).
Check and work up the cases with the staff on the submitted service. Finish the report in the same fashion you would for an in-house surgical and give it to the secretary (see under In-House Service, #4 and #5). Include in the GROSS DESCRIPTION the identity of all submitted slides and blocks, including the outside hospital, as well as the date of the original procedures (which may be different from the report date). With the staff, prepare the form letter to go to the referring pathologist, and identify any slides (special stains) or blocks to be returned.
Our policy is to retain submitted slides in any case in which we render a diagnosis. If we have prepared our own slides from the paraffin blocks, we may then return submitted slides, if they do not demonstrate significantly different pathologic findings, and only if they have been requested by the outside laboratory. Requests for return of submitted slides in cases in which we do not have other material must be cleared with the senior staff. Such requests will usually not be honored if the patient is or has been treated at the NIH Clinical Center. In addition, we try to retain a paraffin block in many instances for further studies.
The resident on submitted service covers frozen section consultations until 12:00 noon.
NCI protocol guidelines require that we document, to the extent possible, the date of diagnostic biopsies. For submitted surgical specimens, this information should be included in the GROSS DESCRIPTION portion of the pathology report, and should be dictated by the resident.
Surgical Pathology Slide and Block Return Policy – It is the policy of the Laboratory of Pathology to retain slides from cases sent in consultation. The standard form letter accompanying pathology reports will reflect this.
Under certain circumstances slides may be returned:
Patient requests return of slides:
Medical Legal Cases:
Release of Slides:
For unforeseen situations not covered by the policy, Dr. Liotta, or in his absence the designated Clinical Director, will make the final decision, or the situation may be referred to the Office of General Counsel.
The Laboratory of Pathology is not a Reference Laboratory.
Intra-Departmental Consultation
Intradepartmental consultations are encouraged in difficult cases and when an expert opinion is needed. Upon review of cases, the staff on service may decide to seek additional opinion. The consultation will be sought by the resident or the attending on the case. If the consulted pathologist requests further information or special tests are deemed necessary, these should be obtained. If further information or special tests are not necessary, a consultation should ideally be completed within 24 hours (exception--case submitted for review by multiple consultants). A case should be resubmitted for consultation following receipt of additional material, further clinical information or completion of special studies. The pathologist in charge of the surgical pathology case must decide whether the results of intra-departmental consultation provide relevant information for inclusion in the patient’s report. If the views of the consulted pathologist are to be reflected in the final report, the interpretation should be included in the note and/or flagged in SoftPath, "Results" section, under "Intra-Departmental Consultation". The consulted pathologist may initial the report and may receive a copy of the final report, if requested.
Extra-Departmental Consultation
As suggested by ADASP (Am J Surg. Pathol 17:743-745, 1993), the accompanying letter to an outside consultant should provide the reason for the consultation, specific questions to be answered, and the referring NIH pathologist’s working diagnosis or differential. The outside consultant should be provided with all available information on the case: clinical history; representative H&E sections of all pathologic findings; the original immunoperoxidae slides or unstained slides and/or blocks; electron microscopy (EM) prints (if EM was performed); flow cytometric data (if flow cytometry was performed); and results of molecular testing. Upon receipt of formal consultation report, the external consultation should be documented via results incorporation in the NIH report (if the case was not signed out yet), which will then be incorporated in the patient’s medical record. Copies are provided to all NIH staff pathologists who may have reviewed the case. Documentation should include: the letter sent to the outside consultation and the written response from the consultant. Documentation of extra-departmental consultations must be readily accessible within the Pathology Department. A copy of the consultation surgical pathology report is maintained with the official NIH surgical pathology (either in the final report, or in a supplemental report). Additionally, a copy of the consultation report is kept separately, and is readily linked to the patient.
Extra-Departmental Cases Submitted to the Laboratory of Pathology, CCR, NCI, NIH
These are entered as submitted cases and they are accessioned according to standard practices of the laboratory, and a report issued. Copies of the NIH-generated report are sent to any referring physicians within the NIH (patient’s treating physicians) and to originating Laboratory.
Informal Inter- or Extra-Institutional Consultation
Informal inter- or extra-institutional consultation for other than personal interest, research or educational purposes is strongly discouraged. When consultation is for diagnostic purposes, a formal reading is absolutely necessary. Under no circumstances, can an informal “consultation” by an NIH pathologist be reflected in any outside surgical pathology report, or used to decide a patient’s treatment.
Consultations Provided to Clinicians Prior to Accessing (Curb Side Consultation)
When a diagnosis is sought before accessioning (i.e., curb side consult), the pathologist may verbally inform a clinician of a preliminary diagnosis with the sole purpose for supporting potential patient protocol enrollment. A formal written NIH surgical pathology report is needed to initiate patient treatment.
In any case in which the final diagnosis is considered significant and/or unexpected (e.g., significantly different from the submitting diagnosis or preoperative diagnosis, change of a frozen section diagnosis after review of permanent sections), the resident and/or staff pathologists responsible for the case should contact the submitting physician and notify him/her of the findings. In case of discrepant frozen sections, the attending who read the frozen section should contact the surgeon and discuss the case. There should be a reasonable effort to ensure that such diagnoses are received by the clinician/surgeon by means of telephone, pager, or other system of notification. Because physicians may not promptly receive copies of reports, it is especially important that we document notification to physicians of significant and/or unexpected pathology findings.
If you are unable to contact the submitting physician, a message should be left with the Clinical Branch Chief or the Clinical Director’s office of the Institute involved. There should be written documentation of notification, including the name of the physician contacted, the name of the person making the contact, and the date and time of the contact. Notification can be made by the resident, "Hot Seat" resident, or staff.
Examples of cases in which notification would be required are as follows:
All verbal reports require read-back of patient's name, medical record, diagnosis and unexpected findings.
When the final pathology report is processed, include in the NOTE the information regarding documentation of communication of these diagnosis. Frozen sections discrepancies should be documented in the surgical pathology report as well as in the Laboratory of Pathology Quality Management files.
Residents on service will have Pathology Alert labels available to them. Spare labels are kept in the Surgical Pathology Office. When the final report is dictated, include in the "Distribution" section the information contained in the Pathology Alert label. If you speak to the clinician after you have dictated the final report, place the Pathology Alert label on the Final Report and issue an addendum to the report.
Further information about the Laboratory of Pathology (LP) can be found on our public Web site. This site contains the detailed Specimen Collection Guide and LP Staff Directory. The LP Web site is a useful supplement to this manual.