Accuracy of intraoperative frozen section diagnosis in spinal cord lesions

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Bethany Carson
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and Dental Hospital Toru Hirano, Kei Watanabe, Keiichi Katsumi,

1 Accuracy of intraoperative frozen section diagnosis in spinal cord lesions Department of Orthopedic Surgery Niigata University Medical and Dental Hospital Toru Hirano, Kei Watanabe, Keiichi Katsumi, Masayuki Ohashi, Naoto Endo Eurospine 2014 ( , Lyon, France) 1

2 Back ground and Purpose Ø It is sometimes difficult to obtain a preoperative correct diagnosis in spinal cord lesions by imaging studies. Ø Intraoperative frozen section (FS) diagnosis is important. How accurate? Purpose: To evaluate the accuracy of the FS diagnosis and to elucidate the pattern of incorrect diagnosis 2

3 Materials & Methods 1985 ~: Among 253 surgically-treated cases with spinal cord lesions, FS diagnosis was made in 155 cases Location of the lesions: Extra-mdullary (EM): 93 cases Dura mater: 1 Extradural*: 4 Dumbbell : 27 Intradural extramedullary (IDEM): 61 Intra-medullary (IM) : 62 cases *metastatic tumors were excluded Analysis: Ø Accuracy of FS diagnosis (FS vs. postoperative definitive) Ø Patterns of incorrect diagnosis 3

4 Accuracy of FS diagnosis in EM lesions (n=93) Accuracy Dural 1/1 (100%) Extradural 4/4 100%) Dumbbell 26/27 (96%) IDEM 60/61 (98%) Total 91/93 (97.8%) Incorrect FS diagnosis (n=2) Location FS diagnosis Definitive diagnosis Dumbbell neurofibroma Malignant neurinoma IDEM Lymphoma Lymphoplasmacyte-rich meningioma 4

5 Definitive diagnosis and accuracy of FS diagnosis in IM lesions Tumor (n=53) Ependymoma: 15 Astrocytoma: 13 Hemangioma: 9 Lipoma: 7 Hemangioblastoma: 3 Neurinoma: 2 Others: 2 Metastasis : 2 Non-tumor (n=9) Inflammatory : 2 Granulomatous: 2 AVF: 2 Demyelinating: 1 Hematoma: 1 Others : 1 Pathology Accuracy Tumor 44/53 (83.0 %) Non-tumor 6/9 (66.7 %) Total 50/62 (80.4 %) 5

6 Comparison in accuracy of FS diagnosis between EM and IM Correct Incorrect Accuracy EM (n=93) % IM (62) % Accuracy of IM lesions was significantly lower than extramedullry lesions (p<0.001, Fisher s exact test). 6

7 Patterns of incorrect diagnosis in IM lesions Pattern 1: Disagreement between tumor and non-tumor (n=5) Tumor in FS Non-tumor in definitive (n=3) Case FS diagnosis Definitive diagnosis 1 Astrocytoma Inflammatory 2 Astrocytoma Inflammatory (choronic) 3 Low grade glioma Granulomatous Non-tumor in FS Tumor in definitive (n=2) Case FS diagnosis Definitive diagnosis 1 Hematoma Hemangioma 2 No tumor cells Astrocytoma 7

8 Patterns of incorrect diagnosis in IM lesions Pattern 2: Disagreement of detailed histological diagnosis of tumors (n=7) Case FS diagnosis Definitive diagnosis 1 Astrocytoma Ependymoma 2 Astrocytoma Ependymoma 3 Astrocytoma Ependymoma 4 Astrocytoma Ependymoma 5 Malignant lymphoma Ependymoma 6 Glioma Metastasis 7 Subependymoma Ependymoma There were 2 cases with disagreement of benign and malignant 8

9 Summary of the results 1. Accuracy of diagnosis of FS in EM lesion was nearly 100%. 2. Accuracy of diagnosis of FS in IM (81%) was significantly lower than EM. 3. There were 2 patterns of incorrect diagnosis of FS in IM Pattern 1; Disagreement between tumor and nontumor (5 cases) Pattern 2; Disagreement of detailed histological diagnosis in tumors (7 cases) 9

10 Why accuracy of FS diagnosis in IM is lower? Ø Limited amount of biopsy specimen Ø Diversity of pathology in IM lesions Ø Difficulty of differential diagnosis between glioma and reactive gliosis in non-tumor lesion Ø Difficulty of proper diagnosis of ependymoma due to the lack of typical findings such as ependymal rosette in small specimen 10

11 Consideration in surgery for IM lesions Ø Enough amount of specimens should be corrected in proper site. Ø Repeated FS diagnosis should be asked, if FS diagnosis is not consistent with pre or intraoperative findings. Ø Only biopsy may be considered when lesion is strongly expected as non-tumor preopratively, even if FS diagnosis is tumor. 11

12 Conclusion Intraoperative surgical strategy especially in IM lesions should be established not only based on the FS diagnosis, but also based on the preoperative clinical course, preoperative imaging studies and intraoperative and neuro-monitoring findings. COI Disclosure : I have no financial relationships to disclose 12

Neuroimaging. spine / spinal cord

Neuroimaging. spine / spinal cord Neuroimaging spine / spinal cord Spine & spinal cord imaging methodology Plain x-ray of spine Computed tomography CT - traditional ( normal CT) - reconstructions - myelo-ct Magnetic resonance MR - standard