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The contemporary utility of intraoperative frozen sections in thyroid surgery
Samuel J Trosman1, Rohith Bhargavan2, Brandon L Prendes1
1Head and Neck Institute, Cleveland Clinic Foundation, United States.
Insights
Intraoperative frozen sections for thyroid nodules have moderate accuracy but a high false negative rate. Routine use may offer limited value for clinical decisions within the Bethesda classification system.
Area of Science:
- Endocrinology
- Surgical Pathology
- Oncology
Background:
- Thyroidectomy is a common surgical procedure.
- Accurate intraoperative diagnosis is crucial for patient management.
- The Bethesda System for Reporting Thyroid Cytopathology standardizes fine needle aspiration results.
Purpose of the Study:
- To evaluate the accuracy of intraoperative frozen section analysis for thyroidectomy specimens.
- To assess the utility of frozen sections in guiding surgical decisions, particularly for indeterminate cases (Bethesda III-V).
Main Methods:
- Retrospective chart review of 74 patients undergoing thyroidectomy with intraoperative frozen sections (2009-2015).
- Analysis of frozen section accuracy (sensitivity, specificity, PPV, NPV, diagnostic accuracy) for malignancy.
- Stratification of results based on Bethesda classification of prior fine needle aspiration.
Main Results:
- Overall diagnostic accuracy for malignancy was 85% (Sensitivity 81%, Specificity 95%, PPV 98%, NPV 66%).
- For indeterminate Bethesda categories (III-V), accuracy was 84% (Sensitivity 81%, Specificity 91%, PPV 95%, NPV 67%).
- False negatives led to 3 reoperations for missed malignancies.
Conclusions:
- Intraoperative frozen sections can be helpful when positive for malignancy.
- The significant false negative rate limits their routine utility in guiding intraoperative management.
- Current data suggests limited value for routine frozen sections in the era of the Bethesda system.
Purpose:
To determine the accuracy of intraoperative frozen section analysis on thyroidectomy specimens stratified by the Bethesda classification scheme and its utility for intraoperative decision-making.
Study Design:
Retrospective chart review.
Methods:
A retrospective review was performed on all patients who underwent thyroidectomy or thyroid lobectomy with intraoperative frozen sections at a tertiary care academic center from 2009 to 2015.
Results:
There were 74 total patients who underwent partial or total thyroidectomy with intraoperative frozen section analysis of a thyroid nodule whom had previously undergone a thyroid fine needle aspiration of the nodule. The sensitivity, specificity, positive predictive value, and negative predictive value for a thyroid frozen section with respect to its prediction for malignancy was 81%, 95%, 98%, and 66%, respectively, with a diagnostic accuracy of 85%. For 37 patients with an indeterminate cytologic diagnosis on fine needle aspiration (Bethesda categories III-V), the sensitivity, specificity, positive predictive value, and negative predictive value for a thyroid frozen section was 81%, 91%, 95%, and 67%, respectively, with a diagnostic accuracy of 84%. False positives and false negatives resulted in 1 completion thyroidectomy for benign pathology and 3 reoperations for malignancy not discovered on frozen section.
Conclusion:
While intraoperative frozen sections on thyroid specimens may be helpful if positive, the false negative rate remains high. There appears to be limited value in routine frozen sections to guide clinical management and decision-making in the era of the Bethesda system.
