Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2012 | Month : September | Volume : 6 | Issue : 7 | Page : 1337 - 1342 Full Version

Accuracy of Frozen Section in Diagnosis of Head and Neck Lesions


Published: September 1, 2012 | DOI: https://doi.org/10.7860/JCDR/2012/.2454
Sphurti Srivastava, Asha Agarwal, Chayanika Pantola, Sonal Amit

1. Resident, Department of Pathology, G.S.V.M. Medical College, Kanpur, India. 2. Professor, Department of Pathology, G.S.V.M. Medical College, Kanpur, India. 3. Lecturer, Department of Pathology, G.S.V.M. Medical College, Kanpur, India. 4. Lecturer. Department of Pathology, G.S.V.M. Medical College, Kanpur, India.

Correspondence Address :
Dr. Sphurti Srivastava
369 H-Block Kidwai Nagar, Kanpur, India.
Phone: +919506008600
E-mail: sphurti.srivastava@gmail.com

Abstract

This study was carried out in the Department of Pathology, GSVM Medical College, Kanpur. 100 neoplastic and non-neoplastic lesions from the head and neck were subjected to frozen section examination and they were compared with permanent sections on the same tissue as well as after further sampling. The specimens included lymph nodes, oral cavity lesions, thyroid lesions, and salivary gland lesions. The accuracy of frozen section in diagnosis of head and neck lesions was 94% with discordance rate of 5% and deferral rate 1%. The disagreements were the result of a gross sampling error in 3 (42.8%) cases, an interpretative error in 2 (28.6%) cases and (14.3%) a microscopic sampling error and inadequate tissue in the frozen section in 1 case each.

Keywords

frozen section, neoplastic and non-neoplastic lesions

Material and Methods

The specimens from Head and Neck lesions of excised malignant lesions were received from Department of Surgery and Otolaryngology, LLR and Associated hospitals, Kanpur. A proper history was taken and a detailed clinical examination was done in every case. After a detailed gross examination and after making a gross provisional diagnosis, the representative tissue sections which measured 3–5mm were submitted for the frozen section procedure by using a rapid sectioning cryostat (LEICA–CM 1510 S). The sections were cut at a thickness of 6–10 microns. The rapid Hematoxylin and Eosin method was employed to stain the sections as per the standard protocol. The remains of the tissues which were used for making the frozen sections were subsequently processed by the paraffin embedding technique, so as to compare the diagnosis of the frozen sections with the permanent sections on the same tissues. The results were also compared with the final, permanent section diagnosis after giving more sections, so as to evaluate the sampling errors, if any. The deferred and the incorrect cases were studied further to determine the reasons for the discrepancies. The classification of the errors which was used in the present study, was based on that which was followed by Rogers (1) et al (1987).
• Gross sampling error: where the lesion was contained in a portion of the tissue which was selected for the cryostat section, but was not sampled.
• Microscopic sampling error: where the lesion was in the tissue which was sampled, but was not revealed in the sections which were studied.
• Interpretation error:where the relevant tissue was on the frozen section slide, but the correct diagnosis was not made.
• Failure of communication: where the surgeon possessed the information that probably would have changed the frozen section diagnosis, had it been communicated to the pathologist.

Results

Hundred (100) cases of head and neck lesions were studied for diagnosis. Out of the 100 cases of the head and neck region, 35 cases (35%) were lymph node lesions, followed by 30 oral cavity lesions (30%), 18 thyroid lesions (18%) and 17 salivary gland lesions (17%).
The Lymph Node Lesions (Table/Fig 1)
35 cervical lymph node specimens were received.Of the 35 cases, 14 were of tubercular lymphadenitis (Table/Fig 2), 12 were of reactive lymphadenitis, 5 were of non Hodgkin’s lymphoma (Table/Fig 3) were of metastatic squamous cell carcinoma. All (85.7%), but 2 (14.3%) cases of tubercular lymphadenitis were correctly diagnosed on the frozen sections. 1 was misdiagnosed as reactive lymphadenitis (interpretative error). In 1 case, there was a microscopic sampling error. All (100%) cases of reactive lymphadenitis were precisely diagnosed on the frozen sections.Among the 5 cases of non-Hodgkin’s lymphoma, all (100%) were correctly diagnosed on the frozen sections. 4 (100%) cervical lymph node specimens were diagnosed as metastatic squamous cell carcinomas on the frozen sections, which was further confirmed on the permanent sections. The accuracy of the frozen section in diagnosing the lymph node lesions was 94.3% and a discrepancy was found in 2 (5.7%) cases.
The Oral Cavity Lesions (Table/Fig 4)
30 oral cavity lesions were submitted for frozen section examination.Of the 30 oral cavity lesions, 3 were benign and 27 were malignant. All the benign lesions were diagnosed as capillary hemangiomas on the frozen as well as the paraffin sections. Of the 27 malignant lesions, 23 cases were squamous cell carcinomas (Table/Fig 5). Of these, 21 were precisely diagnosed on the frozen sections. However, gross sampling errors in the 2 specimens resulted in false negative diagnoses of moderate grade dysplasia with absence of invasion on the frozen sections. All the remaining 4 cases were correctly diagnosed as carcinoma in situ on the frozen sections. Thus, the total diagnostic accuracy in the oral cavity lesions was 93.3% and a discrepancy was found in 2 (6.7%) cases.
The Thyroid Lesions (Table/Fig 6)
18 thyroid tissues were received for the frozen section analysis.Of the 18 thyroid lesions, ten (55.6%) were benign lesions, five (27.8%) were follicular neoplasms and three (16.6%) were papillary carcinomas. Of the ten benign lesions, seven were diagnosed as colloid goiter and three as Hashimoto’s thyroiditis (Table/Fig 7) on the frozen as well as the paraffin sections. All the follicular neoplasms were follicular adenomas and they were correctly diagnosed on the frozen sections.All the 3 malignant lesions were precisely diagnosed as papillary carcinomas (Table/Fig 8) on the cryostat sections, which were confirmed subsequently on the paraffin sections. Thus, the diagnostic accuracy of the frozen sections for the thyroid lesions was 100%.
The Salivary Gland Lesions (Table/Fig 9)
17 salivary gland lesions were submitted for the frozen section study. These included 11 parotid lesions, 3 submandibular lesions, and 3 lesions from the minor salivary gland.Of the 17 salivary gland lesions, 15 were diagnosed correctly on the frozen sections. 8 of these were diagnosed as pleomorphic adenomas, 4 as chronic sialadenitis, 2 as Warthin’s tumour (Table/Fig 10), and 1 as adenoid cystic carcinoma. An interpretative error in 1 case resulted in a false diagnosis of pleomorphic adenoma, owing to the abundant chondromyxoid ground substance and the sparse epithelial structures, which on paraffin section, was diagnosed as carcinoma ex pleomorphic adenoma (Table/Fig 11). A gross sampling error in the other parotid specimen resulted in a false negative diagnosis of absence of tumour. The final diagnosis was deferred for the permanent section examination, which revealed an adenoid cystic carcinoma. Thus, the overall diagnostic accuracy for the salivary gland lesions was 88.2%, a discrepancy was found in 1 (5.9%) case and a deferral was found in 1 (5.9%) case.
The Cause of the Discrepancy
Of the 6 errors which we faced, 3 (50%) were due to gross sampling errors, 2 (33.3%) were due to interpretative errors and 1 (16.7%) was due to a microscopic sampling error.
The Overall Accuracy
The accuracy of the frozen sections in the diagnosis of head and neck lesions was 94%, with a discordance rate of 5% and a deferral rate of 1%.

Discussion

In the present study, 100 neoplastic and non-neoplastic lesions from various head and neck sites were subjected to the frozen section examination for diagnosis and then they were compared with the gold standard paraffin sections, in order to determine the usefulness of this technique. The diagnostic accuracy of this series was assessed by using the conventional measures of sensitivity and specificity and this was compared with the data which was obtained from the Indian and the international literature.
The Lymph Nodes
In the present series, 35 lymph node specimens were subjected to the frozen section analysis. An accuracy of 94.3% was achieved, which was slightly lower than those which were reported in most of the reviews in the literature. Ackerman (2) et al. (1959) and Holaday (3) et al. (1974) found an accuracy of 98.6% and 97.5% respectively for the lymph node frozen sections. Ackerman (2) et al. (1959) affirmed that the evaluation of the cut surface of the lymph nodes was important, since a firm and grey appearance was likely to be microscopically unremarkable, while the fish flesh appearance of lymphoma was well known. The areas of necrosis indicated a pathological process, which may have been due to granulomas or metastasis. The authors did not encounter any difficulty in assigning a diagnosis of lymphoma and they did not feel the necessity to subtype the lymphoma, once the patient was put in this category. Holaday (3) et al. (1974) stated that the improper gross sampling which was done by the surgeon or the pathologist was the reason for the discrepancy. Rogers (1) et al. (1987) came across three false negative results that were traced to the microscopic sampling, while in one case, Hodgkin’s lymphoma was misinterpreted as reactive hyperplasia. Ahmad (4) et al. (2008) also conformed to a similar reason for the error. Oneson (5) (1989) reported a high inconclusive rate of 11%, stating that a higher deferral rate was acceptable in this group, as the prime reason for the consultation had been obtained for the biopsy and for special staining. The microscopic sampling error led to a wrong diagnosis in 1 case (2.9%) and to an interpretative error in 1 case (2.9%). The discordance which was reported by other workers was also significantly low and there was agreement in the reason for the erroneous diagnosis.
The Oral Cavity
In the present study, 30 oral cavity specimens were subjected to frozen section analysis for their diagnoses. 3 were benign and 27 were malignant. All the benign lesions were precisely diagnosed as capillary hemangiomas. Among the 27 malignant lesions, gross sampling errors in 2 specimens resulted in a false negative diagnosis of moderate grade dysplasia. The total diagnostic accuracy in the oral cavity lesions was 93.3%, which was slightly lower, as compared to that in the other studies in the literature, which had looked at the entire head and neck lesions. The slightly lower diagnostic accuracy of the frozen section in the oral cavity lesions can be attributed to the fact that the other studies had included the entire head and neck lesions and this had to be taken in account.
The Thyroid
In the present series, 18 thyroid specimens were subjected to the frozen section analysis. Ten (55.6%) were benign lesions, five (27.8%) were follicular neoplasms and three (16.6%) were papillary carcinomas. This was similar to those in the study which was done by JoĂŁo Paulo (6) et al. (2009). The overall diagnostic accuracy was 100%. Although in this study, no difficulty was experienced in this category, the place of the frozen section in the thyroid was quite controversial. The diagnostic importance of the psammoma bodies in the papillary carcinomas was emphasized by Kraemer (7) et al. (1987), who recommended a prompt search for a nearby carcinoma in such a case. Ackerman (2) et al. (1959) reported a case where, although the psammoma bodies were seen, they were not given the importance that they deserved, leading to a missed diagnosis of a papillary carcinoma. Another unique feature regarding the frozen sections in papillary thyroid carcinomas, is the absence of optically clear nuclei, which is a fixation artifact and one of the most reliable features on the paraffin sections. Kraemer (7) (1987) considers the presence of true papillae as the most reliable feature in the frozen sections. In the analysis which was conducted by Nakazawa (8) et al. (1968), most of the errors were the result of a faulty sampling of the multicentric tumours, while others were attributed to microcarcinomas which were harboured in the glands, which otherwise had the features of goitre. In all these cases, a correct diagnosis could be rendered only after examining multiple paraffin sections. This brought out the difficulties which were encountered in frozen sections of the thyroid. These reasons were also stated by Holaday (3) et al. (1974), who found a 0.6% false negative rate. Nakazawa (8) et al. (1968) also experienced a difficulty in a colloid rich thyroid lesion, which would crumble on cryotomy, accounting for a missed diagnosis of a malignancy in the unsatisfactory preparation. The status of the frozen sections as a cost effective tool was questioned by workers like McHenry (9) et al. (1996), DeMay (10) (1998), and Alonso (11) et al. (2003), since fine needle aspiration biopsy is regarded as the most accurate test, except in the follicular lesions. They opined that there was a low probability of picking up the follicular carcinoma on the frozen sections. Simpson (12) (1998) however contradicted this view and advocated cytology as an adjunct to the frozen sections. The accuracy which was achieved in the present study was 100%, which was superior to that in most of the reports in the literature. However, the fact that these reports looked at a much larger sample size, cannot be underscored.
The Salivary Gland
In the present study, 17 salivary gland lesions were subjected for the frozen section examination. Of these, 82.4% were benign and 17.6% were malignant. This was similar the picture in the study of Allen (13) et al. (1983), Granick (14) et al. (1985), Rigual (15) et al. (1986), Gnepp (16) et al. (1987) and Yong (17) et al. (1996). 15 were diagnosed correctly on the frozen sections. 8 of these were diagnosed as pleomorphic adenomas, 4 as chronic sialadenitis, 2 as Warthin’s tumour, and 1 as an adenoid cystic carcinoma. An interpretative error in 1 case resulted in a false diagnosis of a pleomorphic adenoma, owing to the abundant chondromyxoid ground substance and the sparse epithelial structures, which on the paraffin sections, was diagnosed as carcinoma ex pleomorphic adenoma. A gross sampling error in the other parotid specimen resulted in a false negative diagnosis of absence of tumour. The final diagnosis was deferred for the permanent section examination, which revealed an adenoid cystic carcinoma. Thus, the overall diagnostic accuracy for the salivary gland lesions was 88.2%, a discrepancy was found in 1 (5.9%) case and a deferral was found in 1 (5.9%) case. This was in concordance with the findings in the studies of Yong (17) et al. (1996) and Seethala (18) et al. (2005), while these values were slightly lower than those in other studies.
Assessment of the Discrepancy and the Errors
The primary purpose of the frozen section analysis is to determine the correct pathological process and to decide the therapeutic course of action. Therefore, when it was viewed with respect to the diagnosis of a correct pathological process, 6 out of the 100 frozen sections in the current study were found to be erroneous. This amounted to a discordant diagnosis rate of 6%, which was only due to a false negative error.Ackerman (2) et al (1959) reported 2% errors and they believed that the errors would be reduced to a minimum if the clinical data were available and if the technique which was employed was of a high quality. However, a pathologist must refrain from getting swayed by the overwhelming clinical data and he/she must report only what he/she sees. In the series which was undertaken by Horn (19) (1962), 1.9% lesions were labeled as false negative, while 0.6% lesions were rendered a false positive diagnosis of malignancy. The author is of the view that a false negative diagnosis may simply indicate an unlucky selection of the tissue, but in some cases, especially in those of the thyroid, where the decision requires a lengthy study of multiple sections, these problems may be virtually unavoidable. According to Horn (19) (1962), the incorrect diagnosis of a malignancy was far more important than an incorrect diagnosis of benignancy, as the former could subject the patient to a needless mutilating surgery. Holaday (3) et al (1974) highlighted the significant differences between the frequencies of the false positives and the false negatives. Although a low figure of 1% false negatives was seen, it was still six times the occurrence of the false positives (0.15%). This analysis brought out the overall attitude of the pathologist towards the extreme conservatism. The categorization of the errors which were found in the present study, was based on the review which was made by Rogers (1) et al (1987), with the inclusion of technical artifacts as one of the most potential sources of the errors. In their experience, interpretation errors contributed to 57% of the total errors, while microscopic sampling, gross sampling, and a lack of communication accounted for 24%, 9.5% and 9.5% of the total errors respectively. We divulged from their results, as gross sampling errors were responsible for 40% of the errors in our case. The results of the present study were strongly congruent with those of the study which was done by Nakazawa (8) et al (1968), with respect to the extremely low false positive diagnoses as compared to the false negative diagnoses. The reasons for the discrepancy were also comparable, with gross sampling and misinterpretation being the most frequent factors. The most significant source of the errors in the present study was a faulty gross sampling, which contributed to 50% of the total errors, which was also found by Nakazawa (8) et al (1968), Gandour-Edwards (20) et al (1993) and Ahmad (4) et al (2008) in their studies.
Accuracy of the Frozen Sections
An overall accuracy of 94% was achieved in our study, which was slightly lower than those in most of the reviews in the literature. Ackerman (2) et al (1959), Rogers(1) et al (1987), and Ahmad (4)et al (2008) reported a 100% accuracy for the head and neck frozen sections, while was comparable to that in the studies of Remson (21) et al (1984) and Gandour-Edwards (20) et al (2006), who found accuracies of 96 % and 97.7%.
The New Emerging Techniques and Their Comparison with the Frozen Sections
In the recent times, the role of frozen sections is minimal. Cytology has played a major role in avoiding an intraoperative diagnosis and if at all it is required, then a crush or an imprint smear cytology is a better option. The crush smears are more frequently used in neurosurgical specimens than in other fields. Moreover, microwave processing of the biopsy sections is superior to that of the frozen sections. The microwave processing reduces the preparation time (2-3 hours, which includes the fixation, processing, microtomy, and the staining) and it allows the same-day tissue processing and the diagnosis of the small biopsy specimens without compromising on the overall quality of the histologic sections. In some instances, it is desirable to perform a biopsy and a definitive surgery on the same day, thereby decreasing the patients’ expenses and the requirement for multiple trips between their homes and the referral centres. Reliance on frozen sections with its attendant difficulties of interpretation and greater expenses can be reduced substantially (22). Inspite of the fact that other techniques are there which have got their own advantages, we cannot overlook the importance and the frequent use of frozen sections in surgery.

Conclusion

This study highlighted that inspite of the varied types of diagnoses in head and neck lesions, a reasonably good percentage of accuracy could be achieved in the frozen sections. Also, for the margin assessment like other sites, it plays an important role. Hence, frozen sections should also be used for the diagnosis and the margin assessment in head and neck lesions.

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DOI and Others

ID: JCDR/2012/3840:2454

Financial OR OTHER COMPETING INTERESTS:
None.
Date of Submission: Mar 19, 2012
Date of Peer Review: Jun 09, 2012
Date of Acceptance: Jul 08, 2012
Date of Publishing: Sep 30, 2012

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