title: Utility of frozen section analysis for fungal organisms in soft tissue wound debridement margin determination.
abstract: BACKGROUND
  Zygomycetes cause different patterns of infection in immunosuppressed individuals, including sino-orbito-cerebral, pulmonary, skin/soft tissue infection and disseminated disease. Infections with Zygomycetes have a high mortality rate, even with prompt treatment, which includes anti-fungal agents and surgical debridement. In some centers, clear margins are monitored by serial frozen sections, but there are no specific guidelines for the use of frozen sections during surgical debridement. Studies in fungal rhinosinusitis found 62.5-85 % sensitivity of frozen section analysis in margin assessment. However, the utility of frozen section analysis for margin evaluation in debridement of skin/soft tissue infection has not been published.
  
  
  METHODS
  We present a case of zygomycosis of decubitus ulcers in which we assessed statistical measures of performance of frozen section analysis for presence of fungal organisms on the margin, compared with formalin-fixed paraffin embedded (FFPE) sections as gold standard. A total of 33 specimens (94 blocks) were sectioned, stained with H&E and evaluated by both frozen and FFPE analysis. Negative interpretations were confirmed by Gomori methenamine silver stain on FFPE sections.
  
  
  RESULTS
  H&E staining of frozen sections had 68.4 % sensitivity and 100 % specificity for assessing margins clear of fungal organisms. The negative and positive predictive values were 70.0 % and 100 %, respectively. Using presence of acute inflammation and necrosis as markers of fungal infection improved sensitivity (100 %) at the expense of specificity (42.9 %).
  
  
  CONCLUSIONS
  Use of intraoperative assessment of skin and soft tissue margins for fungal infection is a valuable tool in the management of skin and soft tissue fungal infection treatment.
authors.affiliation: Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio. nives.zimmermann@UC.edu.|Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. nives.zimmermann@UC.edu.
authors.forename: Nives
authors.initials: N
authors.lastname: Zimmermann
authors.affiliation: Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio. matthew.hagen@UC.edu.
authors.forename: Matthew C
authors.initials: MC
authors.lastname: Hagen
authors.affiliation: Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio. Jason.Schrager@UC.edu.
authors.forename: Jason J
authors.initials: JJ
authors.lastname: Schrager
authors.affiliation: Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio. renee.hebbeler-clark@uc.edu.
authors.forename: Renee S
authors.initials: RS
authors.lastname: Hebbeler-Clark
authors.affiliation: Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio. Sreeharsha.Masineni@UC.edu.
authors.forename: Sreeharsha
authors.initials: S
authors.lastname: Masineni
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use; D001706:Biopsy; D004396:Coloring Agents; D003646:Debridement; D004801:Eosine Yellowish-(YS); D005260:Female; D005629:Frozen Sections; D006416:Hematoxylin; D006801:Humans; D016867:Immunocompromised Host; D007430:Intraoperative Care; D008875:Middle Aged; D009091:Mucormycosis / Q000175:diagnosis / Q000276:immunology / Q000382:microbiology* / Q000601:surgery*; D016612:Paraffin Embedding; D011237:Predictive Value of Tests; D003668:Pressure Ulcer / Q000175:diagnosis / Q000276:immunology / Q000382:microbiology* / Q000601:surgery*; D012233:Rhizopus / Q000302:isolation & purification*; D018461:Soft Tissue Infections / Q000175:diagnosis / Q000276:immunology / Q000382:microbiology* / Q000601:surgery*; D013194:Staining and Labeling; D016707:Tissue Fixation; D014946:Wound Infection / Q000175:diagnosis / Q000276:immunology / Q000382:microbiology* / Q000601:surgery*
chemical_list: D000935:Antifungal Agents; D004396:Coloring Agents; D004801:Eosine Yellowish-(YS); D006416:Hematoxylin