"Retired" general orthopedic surgeon who had his license suspended by KY in 1994. Case #467, so take my opinion in context and with a huge grain of salt. It seems to me this the case boils down to whether the initial surgery should have been an open or percutaneous BX rather than "winging it"on the OR table with a possible one shot definitive procedure.
Because of the lack of certainty inherent in some cases of osteoblastoma vs osteosarcoma, even when special stains are available on a delayed basis as opposed to relying on a "shooting from the hip" determination on the spot by frozen section, even with the most careful review of preoperative radiology studies notwithstanding, my opinion is that this poor kid was a goner, no matter what. Yes, bone auto and allografting made it worse, but expecting to resect the tumor completely and getting a cure is unrealistic when it is in such a vital strategic location with vital structures crowded all around even if a "complete" C3 corpectomy with all apparent margins had been performed compared to a complete resection of an expendable bone like a fibula. A limited Bx would have introduced contamination anyway. It was a total C-3 corpectomy. Would that have been deemed too aggressive in what may have simply been an osteoblastoma?
By soliciting an expert opinion, basically this is in a way analogus to "survivorship bias." Any expert already has been tipped off that there was something wrong if this is the only case he is asked to review. It would be interesting to slip in cases where the outcome was not disclosed, and see how many of these other cases that expert "criticizes"and then determine which of these cases he was correct in his predictive opinion. The fact that case presentations are the staple of medical conferences where attendees constantly disagree on diagnosis and treatment relegates this to Monday morning quarterbacking.
I understand the reference to the word "reasonable" as in reasonable care here in the expert's opinion. But what are the defensible limits of reasonable care? For example, diagnosing this case as osteomyelitis and placing him on vancomycin empirically with no blood cultures or lesion aspiration could be care that fell below a "reasonable standard." But not this. This is just as the late great Neil Peart wrote about so elequently in his song "Roll the Bones. "
"We come into this world and take our chances. Fate is just the weight of circumstances."
Thanks for the comment! Every expert like to has an opinion about what is "reasonable" but in the end we've decided to leave that determination to a few lay people. They usually get it right but sometimes they don't.
This is a freak case to be honest. Osteosarcoma in cervical spine that did not burst out of the vertebra for months (assuming this because otherwise it would look more malignant in the imaging, ringing alarm bells. I don't know if closing the patient at that point would make any difference. Sad case for both parties.
The only slides mentioned are frozen sections…those preparations have poor cell morphology and are suboptimal for a definitive diagnosis. There must have been other slides made, as well as additional stains and molecular testing. The pathology section seems sparse… There’s no way the final diagnosis was made from a frozen section!!
I've gotten this same feedback from a bunch of pathologists! I found the pathology expert opinions and am going to get them published in a week or two! Didn't realize how important they were...
Awesome, I look forward to reading it! I really enjoy these cases.
Usually intra-operative frozen sections are done to see if margins are clear or to get a preliminary read on a tissue. Its usefulness is how fast it can be read, but it’s done at the expense of tissue morphology/resolution. It’s like the difference between a Polaroid and a high-res print from a DSLR camera.
Unfortunately it turned out to be a bit of a dud... it was just a copy/paste of the same pathology opinion already published above. There was only one small addition stating that they "failed to make the correct pathologic diagnosis of osteosarcoma even on permanent sections". Confirms your point that they didn't make a final diagnosis on frozen sections but not really any additional info about other stains/molecular testing. Sorry!
I am aware of cases of this type (only one in the spine) - the distinction between osteosarcoma and osteoblastoma can be difficult under the best of circumstances. Frozen section is not the "best of circumstances". I would think that in this and similar cases, "Favor" is not a strong enough report to base additional surgery. At the very least, it implies at least some degree of uncertainty.
In this situation, it is best to communicate with the surgeon in the OR to discuss what the surgeon is observing and planning to do.
That is the time to give the surgeon a sense of the degree to which the pathologist can be sure of the diagnosis. In this case, it would have been better to impart that level of uncertainty: "osteoblastoma with atypical features" should have been a massive red flag.
Communication with the goal of reaching understanding is the best approach. A written report is not always the best way to communicate in the acute instant.
BTW, I suspect with the story of this case, there is essentially no way this child would survive this disease - regardless of treatment.
That's a very interesting point about written vs verbal communication. I've certainly noticed this with radiology from time to time, sometimes what they call and say during a critical finding call has a different sense of urgency than the written report.
I've also wondered about putting % confidence in reports. Saying you're 65% confident about XYZ finding reads differently than writing a report with a lot of hedging. I've used an AI EKG app that gave percentages for how confident it was about a STEMI which I thought was really interesting.
"Retired" general orthopedic surgeon who had his license suspended by KY in 1994. Case #467, so take my opinion in context and with a huge grain of salt. It seems to me this the case boils down to whether the initial surgery should have been an open or percutaneous BX rather than "winging it"on the OR table with a possible one shot definitive procedure.
Because of the lack of certainty inherent in some cases of osteoblastoma vs osteosarcoma, even when special stains are available on a delayed basis as opposed to relying on a "shooting from the hip" determination on the spot by frozen section, even with the most careful review of preoperative radiology studies notwithstanding, my opinion is that this poor kid was a goner, no matter what. Yes, bone auto and allografting made it worse, but expecting to resect the tumor completely and getting a cure is unrealistic when it is in such a vital strategic location with vital structures crowded all around even if a "complete" C3 corpectomy with all apparent margins had been performed compared to a complete resection of an expendable bone like a fibula. A limited Bx would have introduced contamination anyway. It was a total C-3 corpectomy. Would that have been deemed too aggressive in what may have simply been an osteoblastoma?
By soliciting an expert opinion, basically this is in a way analogus to "survivorship bias." Any expert already has been tipped off that there was something wrong if this is the only case he is asked to review. It would be interesting to slip in cases where the outcome was not disclosed, and see how many of these other cases that expert "criticizes"and then determine which of these cases he was correct in his predictive opinion. The fact that case presentations are the staple of medical conferences where attendees constantly disagree on diagnosis and treatment relegates this to Monday morning quarterbacking.
I understand the reference to the word "reasonable" as in reasonable care here in the expert's opinion. But what are the defensible limits of reasonable care? For example, diagnosing this case as osteomyelitis and placing him on vancomycin empirically with no blood cultures or lesion aspiration could be care that fell below a "reasonable standard." But not this. This is just as the late great Neil Peart wrote about so elequently in his song "Roll the Bones. "
"We come into this world and take our chances. Fate is just the weight of circumstances."
This kid was dealt a rotten hand. by fate.
Thanks for the comment! Every expert like to has an opinion about what is "reasonable" but in the end we've decided to leave that determination to a few lay people. They usually get it right but sometimes they don't.
This is a freak case to be honest. Osteosarcoma in cervical spine that did not burst out of the vertebra for months (assuming this because otherwise it would look more malignant in the imaging, ringing alarm bells. I don't know if closing the patient at that point would make any difference. Sad case for both parties.
The only slides mentioned are frozen sections…those preparations have poor cell morphology and are suboptimal for a definitive diagnosis. There must have been other slides made, as well as additional stains and molecular testing. The pathology section seems sparse… There’s no way the final diagnosis was made from a frozen section!!
I've gotten this same feedback from a bunch of pathologists! I found the pathology expert opinions and am going to get them published in a week or two! Didn't realize how important they were...
Awesome, I look forward to reading it! I really enjoy these cases.
Usually intra-operative frozen sections are done to see if margins are clear or to get a preliminary read on a tissue. Its usefulness is how fast it can be read, but it’s done at the expense of tissue morphology/resolution. It’s like the difference between a Polaroid and a high-res print from a DSLR camera.
Hi! Was that other pathology information published? Still curious what their other slides/testing entailed!
Unfortunately it turned out to be a bit of a dud... it was just a copy/paste of the same pathology opinion already published above. There was only one small addition stating that they "failed to make the correct pathologic diagnosis of osteosarcoma even on permanent sections". Confirms your point that they didn't make a final diagnosis on frozen sections but not really any additional info about other stains/molecular testing. Sorry!
No worries! Thanks for the response! I was just checking because I thought maybe I had missed it getting posted
I am aware of cases of this type (only one in the spine) - the distinction between osteosarcoma and osteoblastoma can be difficult under the best of circumstances. Frozen section is not the "best of circumstances". I would think that in this and similar cases, "Favor" is not a strong enough report to base additional surgery. At the very least, it implies at least some degree of uncertainty.
In this situation, it is best to communicate with the surgeon in the OR to discuss what the surgeon is observing and planning to do.
That is the time to give the surgeon a sense of the degree to which the pathologist can be sure of the diagnosis. In this case, it would have been better to impart that level of uncertainty: "osteoblastoma with atypical features" should have been a massive red flag.
Communication with the goal of reaching understanding is the best approach. A written report is not always the best way to communicate in the acute instant.
BTW, I suspect with the story of this case, there is essentially no way this child would survive this disease - regardless of treatment.
That's a very interesting point about written vs verbal communication. I've certainly noticed this with radiology from time to time, sometimes what they call and say during a critical finding call has a different sense of urgency than the written report.
I've also wondered about putting % confidence in reports. Saying you're 65% confident about XYZ finding reads differently than writing a report with a lot of hedging. I've used an AI EKG app that gave percentages for how confident it was about a STEMI which I thought was really interesting.