Q&A column, 5/15

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Editor: Frederick L. Kiechle, MD, PhD

Submit your pathology-related question for reply by appropriate medical consultants. CAP TODAY will make every effort to answer all relevant questions. However, those questions that are not of general interest may not receive a reply. For your question to be considered, you must include your name and address; this information will be omitted if your question is published in CAP TODAY.

Q. I am a pathologist practicing in a small community hospital. I was involved with a patient who was declared brain-dead and subsequently designated a donor of multiple organs. The organ procurement agency ordered additional testing during the two days before the organ harvest, including a CT scan of the chest. The latter revealed a solitary pulmonary nodule.

On the evening of the harvest, I was asked to perform a frozen section assessment of the nodule. I refused initially but finally relented when hospital administration intervened on behalf of the procurement agency. The frozen section revealed a completely necrotic nodule; my differential diagnosis included caseating granuloma and necrotic tumor. Based on my frozen section diagnosis, harvesting was abandoned. The cryostat was decontaminated the next morning. Permanent sections demonstrated coccidioidomycosis.

Pathologists are rarely asked to do frozen sections on nodules to establish a new diagnosis. In most cases, the diagnosis has been established on a previous formalin-fixed biopsy. In a case of a potential explant of organs, even if I am 99.99 percent sure that a nodule is benign and noninfectious by frozen section, there is still a risk for a misdiagnosis, which would be disastrous for all recipients. It would be prudent to defer the frozen section at the time of organ harvesting. Therefore, what is the point of doing a frozen section assessment?

Since there was a two-day window of opportunity, a CT-guided biopsy of the pulmonary nodule could have been performed. This biopsy would have resulted in a definitive diagnosis, circumventing the need for organ harvesting. Is this a reasonable and feasible approach?