title: Root cause analysis of problems in the frozen section diagnosis of in situ, minimally invasive, and invasive adenocarcinoma of the lung.
abstract: BACKGROUND
  Frozen sections can help determine the extent of surgery by distinguishing in situ, minimally invasive, and invasive adenocarcinoma of the lung.
  
  
  OBJECTIVE
  To evaluate our experience with the frozen section diagnosis of these lesions using root-cause analysis.
  
  
  METHODS
  Frozen sections from 224 consecutive primary pulmonary adenocarcinomas (in situ, 27 [12.1%]; minimally invasive, 46 [20.5%]; invasive, 151 [67.4%]) were reviewed. Features that could have contributed to frozen section errors and deferrals were evaluated.
  
  
  RESULTS
  There were no false-positive diagnoses of malignancy. Frozen section errors and deferrals were identified in 12.1% (27 of 224) and 6.3% (14 of 224) of the cases, respectively. Significantly more errors occurred in the diagnosis of in situ and minimally invasive adenocarcinoma than in the diagnosis of invasive adenocarcinoma (P < .001). Frozen section errors and deferrals were twice as frequent in lesions smaller than 1.0 cm (P = .09). Features significantly associated with errors and deferrals included intraoperative consultation by more than one pathologist (P = .003) and more than one sample of frozen lung section (P = .001). Inflammation with reactive atypia, fibrosis/scar, sampling problems, and suboptimal quality sections were identified in 51.2% (21 of 41), 36.6% (15 of 41), 26.8% (11 of 41), and 9.8% (4 of 41) of the errors and deferrals, respectively (more than one of these factors was identified in some cases). Frozen section errors and deferrals had significant clinical impact in only 4 patients (1.8%); each had to undergo completion video-assisted thoracoscopic lobectomy less than 90 days after the initial surgery.
  
  
  CONCLUSIONS
  The distinction of in situ from minimally invasive adenocarcinoma is difficult in both frozen and permanent sections. We identified several technical and interpretive features that likely contributed to frozen section errors and deferrals and suggest practice modifications that are likely to improve diagnostic accuracy.
authors.affiliation: Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. walts@cshs.org
authors.forename: Ann E
authors.initials: AE
authors.lastname: Walts
authors.forename: Alberto M
authors.initials: AM
authors.lastname: Marchevsky
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis* / Q000473:pathology; D000077192:Adenocarcinoma of Lung; D002278:Carcinoma in Situ / Q000175:diagnosis / Q000473:pathology; D057210:Delayed Diagnosis / Q000517:prevention & control; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control; D005629:Frozen Sections; D006786:Hospitals, Urban; D006801:Humans; D015141:Los Angeles; D008175:Lung Neoplasms / Q000175:diagnosis* / Q000473:pathology; D009361:Neoplasm Invasiveness / Q000175:diagnosis / Q000473:pathology; D010338:Pathology, Clinical / Q000379:methods*; D060891:Root Cause Analysis; D047368:Tumor Burden; D000078329:Workforce