Utility of intraoperative frozen sections in surgical decision making for acute invasive fungal rhinosinusitis

Papagiannopoulos, Peter; Lin, Diana Murro; Al‐Khudari, Samer; Rajan, Kumar B.; Reddy, Swathi B.; Gattuso, Paulo; Tajudeen, Bobby A.; Batra, Pete S.

doi:10.1002/alr.21918

Cited by 26 publications

(25 citation statements)

References 11 publications

(21 reference statements)

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“…In our study the false NEG rate for the FS DX in AIFRS was 19%, which correlates with that in the literature ranging from 12.5 to 27.3% [8, 10, 11]. This rate, however, does not truly reflect the difficulty posed in its FS DX.…”

Section: Discussionsupporting

confidence: 82%

“…Thus, a rapid and accurate diagnosis (DX) is crucial in providing timely and effective treatment. Histopathologic analysis by frozen section (FS) has become a preferred diagnostic method owing to its rapid turnaround in the DX of AIFRS [8–11] but its accuracy is diminished by difficulties in recognizing the disease. We theorize this may be in part because a detailed histomorphologic description of this disease process as seen on FS has not been documented in the literature.…”

Section: Introductionmentioning

confidence: 99%

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Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain

Crist

Hennessy

Hodos

et al. 2018

Head and Neck Pathol

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Acute invasive fungal rhinosinusitis (AIFRS) is a fulminant infection in immunocompromised patients requiring rapid diagnosis (DX), frequently made on frozen section (FS) of sinonasal biopsies, followed by prompt surgical debridement. However, FS interpretation is often difficult and DX sometimes not possible. In this study we sought to characterize reasons for misinterpretation and methods to improve diagnostic accuracy. The FS slides from 271 biopsies of suspected AIFRS in a 16-year period were reviewed and the morphologic features evaluated for their utility in DX. Recurring specific patterns of necrosis were identified, which to our knowledge have not been described in the literature. Although they provide strong evidence for AIFRS, identifying fungus consistently in necrotic tissue is essential for DX. Clues to identifying fungus and pitfalls in misidentification were identified, but even with expert knowledge of these, a gap in accurate DX remained. The key to FS DX of AIFRS is to improve fungus identification in necrotic tissues. Methods had been sought in the past to stain fungus at FS without consistent success. The Periodic Acid Schiff's Reaction for Fungi was modified by our histopathology department for use on frozen tissue (PASF-fs) resulting in effective staining of the fungus. It stained fungus on all 62 positive slides when applied retrospectively over hematoxylin and eosin (H&E) stained FSs and used prospectively at FS for DX. Although knowledge of histologic morphology on FS is important, the crucial value of this study is the novel use of PASF-fs to identify fungus in the DX of AIFRS.

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Section: Discussionsupporting

confidence: 82%

Section: Introductionmentioning

confidence: 99%

Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain

Crist

Hennessy

Hodos

et al. 2018

Head and Neck Pathol

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“…Debridement and antifungal therapy are indicated at times in the absence of a definitive pathologic diagnosis. 8,10,11 The most significant potential for reduction in falsenegative diagnoses was demonstrated by the ability of the PASF-fs to identify fungus when applied to all 61 frozensection slides that contained fungus. Furthermore, when the PASF-fs stain was applied to the slides from the 7 cases that received a false-negative diagnosis on frozen section, it was able to identify invasive fungus in 5 cases (Tables 2 and 3).…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, evaluation of biopsies on frozen section has become the preferred method of diagnosis. [7][8][9][10][11] However, historically, frozen sections have not been as sensitive for AIFRS as routine histologic processing. 8,9 Reasons for this have been attributed to pathologic changes in tissues in AIFRS and the difficulty in identifying fungus on frozen sections.…”

mentioning

confidence: 99%

Frozen Section as a Rapid and Accurate Method for Diagnosing Acute Invasive Fungal Rhinosinusitis

Hennessy

McGinn

White

et al. 2018

Otolaryngol.--head neck surg.

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Objective Identify methods to improve the frozen-section diagnosis of acute invasive fungal rhinosinusitis. Study Design Biopsies with frozen section for suspected acute invasive fungal rhinosinusitis were reviewed to identify causes for missed diagnoses and evaluate methods for potential improvement. Setting All aspects of the study were performed at the Penn State Milton S. Hershey Medical Center. Subjects and Methods All frozen sections performed for suspected acute invasive fungal rhinosinusitis between 2006 through 2017 were reviewed with their diagnoses compared to the final diagnoses. Sensitivity and specificity were determined for each biopsy specimen to evaluate the diagnostic method and for each patient for its effectiveness on outcome. Causes for frozen-section failures in diagnosis were identified. A periodic acid-Schiff stain for fungus (PASF) was modified for use on frozen tissue (PASF-fs) and applied both retrospectively and prospectively to frozen sections to determine its ability to identify undetected fungus and improve diagnostic sensitivity. Results Of 63 biopsies positive for acute invasive fungal rhinosinusitis, 51 were diagnosed on frozen section, while 61 were identified by including the novel PASF-fs stain, reducing the failure rate from 19% to 3%. Of 41 cases that were positive, 34 were diagnosed on frozen section. Of the 7 that were not, 5 were identified by including the PASF-fs, reducing the failure rate from 17% to 5%. Conclusions Frozen section interpretation of biopsies for suspected acute invasive fungal rhinosinusitis using a PASF-fs stain should enable a rapid and accurate diagnosis with improved outcomes by shortening the time to surgery.

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“…El análisis de muestras de sección congelada también puede ser considerada una herramienta efectiva para guiar la decisión intraoperatoria en el debridamiento endoscópico. Sin embargo, el VPN relativamente bajo sugiere que los resultados negativos no necesariamente descartan la presencia de invasión fúngica, por lo que el manejo quirúrgico adicional debe basarse además en la sospecha clínica y los hallazgos endoscópicos intraoperatorios 20 . Un estudio reciente comparó los resultados obtenidos con la sección congelada usando tinciones habituales (hematoxilina y eosina) con respecto a la biopsia deferida, además de utilizar de manera retrospectiva y prospectiva una tinción de PAS para hongos modificada para usar en tejidos congelados (PASF-fs).…”

Section: Diagnósticounclassified

Rinosinusitis fúngica invasiva aguda: Actualización en pacientes adultos y pediátricos

et al. 2019

Rev. Otorrinolaringol. Cir. Cabeza Cuello

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Utility of intraoperative frozen sections in surgical decision making for acute invasive fungal rhinosinusitis

Cited by 26 publications

References 11 publications

Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain

Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain

Frozen Section as a Rapid and Accurate Method for Diagnosing Acute Invasive Fungal Rhinosinusitis

Rinosinusitis fúngica invasiva aguda: Actualización en pacientes adultos y pediátricos

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