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Frozen Section

Any tissue removed from a patient must come through the surgical pathology gross room and to the pathologist’s attention. Located next to the operating room suites, pathologists and surgeons could quickly consult on problematic cases. The close proximity facilitated timely delivery of specimens by the OR nurses. Other specimens arrived from the gastrointestinal endoscopy suites, urology endoscopy suites, and pulmonology bronchoscopy suites. Radiology contributed with biopsies obtained by CT or ultrasound guidance.

Faded photographs of exotic objects removed from the bowels and buttocks of patients were taped to the cabinets. Inside the cabinets, a museum of pickled placentas, stomachs, breasts, and various sizes of orthopedic metal hardware and old cardiac pacemakers lay waiting for eventual disposal.

Franklin Washington’s kingdom was built upon this decaying mass of tissue. He was a pathology assistant, a PA, a title he inflicted upon everyone within earshot. Hospital employees mistakenly interpreted PA as shorthand for a physician’s assistant, a far more common term. Franklin lost no time correcting their ignorance further stressing the fact that a PA was only earned with a master's degree.

Franklin was 47 years old but his muscular build, accentuated by surgical scrubs a size too small for him, halved his age in the eyes of his female associates. His café-au-lait complexion, a combination of a Greek mother and Puerto Rican father, was deepened by innumerable hours sunning himself on the front lawn of the hospital, much to the chagrin of hospital administrators.

Franklin's assisted the residents and attendings with gross examination and dissection of surgical specimens as well as the frozen section. New residents tired of his pedantic chatter, reminding them of his former position at a prestigious hospital in Boston. It was the gold standard for the training of pathology residents, he bemoaned to the uninterested ears. "At Boston, I had my own office, my own phone. They treated me with appropriate respect."

"Then go back there!" Dan shouted back.

"Who would make sure you don't screw up, Doc?"

At 7:30 AM, the operating rooms began the day's cases. The OR schedule, posted in every office, had a yellow highlight through cases that may require an intra-operative consultation. Franklin dutifully reviewed the schedule and retrieved the previous paperwork and slides of any case, previously biopsied or with a prior surgery. In this manner, a pathologist reviewed the original pathology material with the current case. New cases arriving in the gross room would be organized by Franklin with the corresponding paperwork, assigned a case number, and then linked with a computerized database. Tissue cassettes labeled with the case number were prepared and placed alongside the appropriate case.

Small biopsies such as needle biopsies of breast or prostate and punch biopsies of skin were usually grossed in by Franklin. Larger complicated cases such as colon or stomach resections, were dissected by the residents, under Franklin's supervision.

"Uh...Doc...you better squish that fat pad a bit more, there are a few more lymph nodes for you to find."

James bristled at Franklin's remarks, but the emulsified fat between his fingers revealed two additional tan lymph nodes.

"That's it...you're gonna make it!"

Carlos entered the room in time to hear Franklin's comment. Catching James' glance, he rolled his eyes and mouthed, "Ignore him."

"James...you're going to get a thyroid lobectomy on a case I did the FNA on last week. Haas and I thought it was a follicular neoplasm but there were some cytologic features suggestive of papillary carcinoma so we recommended an excisional biopsy. They're going to need a frozen. Call me when it comes...I want to see it. Thanks!"

A frozen section on a thyroid lobectomy was a common intra operative consultation. Depending upon the diagnosis rendered at the time of frozen section, the surgeon may opt for a total thyroidectomy, a complete removal of the both lobes of the thyroid. James turned to Franklin to request the previous cytology slides on the case.

"Way ahead of you, Doc. Got the slides and the previous cytology report waiting at the scope for you."

James forced a smile and muttered an inaudible thanks. Discarding his soiled gloves, James removed his apron, and positioned himself at the microscope, placing a slide on the stage. His review was interrupted when the nurse from the OR arrived, holding a thyroid lobe on a green surgical cloth. "Room 5, Dr. Martin's case." Franklin took the specimen's paperwok and entered the patient's data into the computer, assigning it a case number.

"Let's rock and roll! I'll ink it for you then you can slice and dice with your Ginsu!"

Franklin painted the surface of the thyroid in black ink, designating the true surgical margins and capsule of the thyroid. The lobe was measured, weighed, and positioned in front of James, with a dot of green ink strategically placed on the superior margin.

"Don't eat it all at once, Doc!"

The thyroid lobe was about the size of a small chicken egg. A few slices with the scalpel bread-loafed the specimen, creating slices at about 1 cm intervals. Halfway through the dissection, a tan nodule appeared, cutting with a gritty consistency.

"You found the cream filling!"

"Franklin, please get me two clean glass slides. I want to make a scrape prep of this surface."

James positioned the glass slide and lightly scraped the surface of the tumor. Taking another slide and gently placing it atop the first, the two slides adhered spreading into a thin film of cells and blood. With a quick motion, James pulled the two slides apart, creating an equivalent smear on both slides. Allowing one slide to air dry, the second slide was placed in alcohol and handed to Franklin. "Stain this up with H and E."

"The air dried slide for Diff-Quik stain?"

James nodded and positioned his scalpel along the long axis of the thyroid, slicing a representative section about the size of a nickel, from the tumor. The section sampled the inked margin and the tumor. "I'll use this section for the frozen section."

"You got it, boss!"

The tumor sample was placed on the metal platform, the chuck. A quick freezing polymer was added to the sample, which engulfed it in a dripping mass overflowing over the edges of the chuck. The entire chuck was placed in the cyrostat, set at -20C. Within a minute, the tissue and polymer had frozen white. Franklin retrieved the chuck and positioned it behind the metal blade located within the crytostat. Securing the chuck, James deftly moved the razor sharp blade to within few millimeters of the frozen tissue. His right hand turned the large wheel connected to the cryostat which advanced the blade in increments of 4 microns, shaving off wafer thin sections of the frozen tissue. The outline of the red-brown thyroid tumor contrasted with the surrounding frozen white polymer. His left hand positioned a small paint brush next to the thin sections of tissue, as the sections were teased from the chuck. James placed a clean glass slide into the cryostat, gingerly touched the frozen section, and allowed it to anneal to the warm slide. The completed slide was quickly placed into an alcohol fixative. "One down..." James glanced at the second hand of the clock. "In at 5 after!"

He was very familiar with the cryostat. During his first week, Dan introduced him to the instrument. "You'd better learn how to cut a good frozen section. Your life depends upon it."

He wasn't kidding. The frozen section was one of the most difficult diagnostic tasks that faced the surgical pathologist. It separated the good pathologist from the great pathologist. But no diagnosis could be rendered if a poor section was obtained. Every night, after work, James labored to master this metallic beast. The razor sharp blade had captured the fingers of many an unwary resident as the tissue sections were cut. James' sections were impeccable, a tribute to his father's genes that passed his surgical skills on to his son. Before other residents had even cut their first frozen section, James had perfected his technique. Attendings took notice of his dedication but James was nonplussed by the compliments. He was expected to master this, as quickly as a surgeon needed to master the art of tying knots. It was the absolute minimum that he expected of himself before he could even begin to function as a pathologist.

Franklin took the slide, now placed in a metal slide carrier, and placed it through a series of tissue stains and alcohol rinses. Within 3 minutes, the tissue was stained. A small drop of adhesive was placed on the tissue section and covered with a glass cover slip; the slide was ready for microscopic viewing. James repeated the regimen for a second deeper section, handed the completed section to Franklin, and positioned himself at the microscope to view the fruits of his labor.

"Ready?" Carlos and Dan walked in at the same time. "Let's take it to the multi-head scope." James obliged and took the flat of slides to the conference room microscope so the three of them could view the slides.

"Let's see what we have..." Dan quickly scanned the slide at low power. "Follicular neoplasm, capsule looks intact, no invasion." Dan flipped the microscope objective to a higher power. "Hmm don't know why, but I am getting a papillary feel for this. Is there a scrape prep on this?"

James handed the stained slide to Dan. "Good job, James. Ah...there it is, little Orphan Annie!"

Dan and Carlos both smiled as they recognized the characteristic cytologic findings of nuclear inclusions within the cells. James feigned understanding but his face betrayed his confusion. "James, you didn't grow up here. Little Orphan Annie is a cartoon character that was drawn with empty eyes. Several years ago, a pathologist noted that papillary carcinomas of the thyroid had a characteristic inclusion within the nuclei that resembled these empty eyes. So, we call them Orphan Annie eye nuclei. Cute, huh?"

James nodded. "That's exactly why you were concerned about when you saw the initial FNA on this case."

"Good call, Carlos. All right, James, tell the surgeon that it's a papillary carcinoma, they'll go ahead with the complete thyroidectomy."

The remaining lobe of the thyroid was soon delivered to the gross room. After inking and slicing this thyroid lobe, James returned to the microscope to review the frozen sections. He was a master of the technical performance for the frozen section but the microscopic interpretation still eluded him. It was frustrating to be half a pathologist. He could describe a samba but was unable to perform it. He scanned the slide, attempting to discern the patterns hidden amongst the hues of the blue and red tissue stains. He still struggled with identifying which organ the tissue was taken from. How could he get past this basic level and make a difference for the patient? The other pathology interns appeared so confident, no accents, all graduates of American medical schools. He knew he would have to work twice as hard as everyone else to prove his worthiness. When would it come together for him?

"Nice frozen sections and scrape prep, James."

"Thanks Carlos. Do you have a minute?"

"Sure...want me to go over the frozen section with you?"

"Do you mind? I don't understand why you called it a papillary carcinoma. There is nothing papillary about it, just follicular."

Carlos nodded. "Yup, you got it. The architecture of the tumor is follicular but the cytology is papillary. This is an uncommon variant of a papillary carcinoma which, for a long time, was misdiagnosed as a follicular adenoma, a benign tumor. Only after some of these cases metastasized did someone re-examine them and realize it was really a papillary carcinoma masquerading as a follicular neoplasm. Pretty subtle, eh?"

"So it's the cytologic features that make the diagnosis."

"Uh huh...that's why it was great you did a scrape prep on it. That's what Dan and I were looking for. We suspected it on the frozen but frozen sections are too thick. You can really nail it on a scrape prep. If we called it a follicular adenoma, they would have stopped the surgery and not completed the thyroidectomy. When we get our permanent sections tomorrow, we would have to change the diagnosis to a cancer. The surgeons would have a cow and take the patient back to surgery to remove the other thyroid lobe. They'll tell everyone that pathology screwed up the case...which of course, would be true."

"Of course..." It's always pathology's fault, James thought.

Franklin leaned over the microscope in time to hear the last words of Carlos. "Yeah...and when you screw up too often, its sayonara!"

"So why are you still here?"

"Dr. Haas likes my eyes!"

The intercom announced another frozen section. It could barely be heard over the laughter.

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