Getting it Right the First Time: Frozen Sections for Diagnosing Necrotizing Soft Tissue Infections
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ORIGINAL SCIENTIFIC REPORT
Getting it Right the First Time: Frozen Sections for Diagnosing Necrotizing Soft Tissue Infections Femke Nawijn1
•
Falco Hietbrink1 • Marijke R. van Dijk2
Accepted: 6 September 2020 Ó The Author(s) 2020
Abstract Background The aim of this study was to investigate which histopathologic findings are most indicative for necrotizing soft tissue infections (NSTIs) in ambivalent cases. Methods Patients undergoing surgical exploration for suspected NSTIs with obtainment of incisional biopsies for histopathological assessment were included from January 2013 until August 2019. The frozen sections and formalin-fixed paraffin-embedded (FFPE) samples were retrospectively re-assessed. The primary outcome was the discharge diagnosis. Results Twenty-seven (69%) biopsies of the 39 included samples were from patients with NSTIs. Microscopic bullae (p = 0.043), severe fascial inflammation (p \ 0.001) and fascial necrosis (p \ 0.001) were significantly more often present in the NSTI group compared to the non-NSTI group. Muscle edema (n = 5), severe muscle inflammation (n = 5), muscle necrosis (n = 8), thrombosis (n = 10) and vasculitis (n = 5) were most frequently only seen in the NSTI group. In thirteen tissues samples, there were some discrepancies between the severity of findings in the frozen section and the FFPE samples. None of these discrepancies resulted in a different diagnosis or treatment strategy. Conclusion Microscopic bullae, severe fascial or muscle inflammation, fascial or muscle necrosis, muscle edema, thrombosis and vasculitis upon histopathological evaluation all indicate a high probability of a NSTI. At our institution, diagnosing NSTIs is aided by using intra-operative frozen section as part of triple diagnostics in ambivalent cases. Based on the relation between histopathologic findings and final presence of NSTI, we recommend frozen section for diagnosing NSTIs in ambivalent cases.
& Femke Nawijn [email protected]
Abbreviations AUC Area under the curve ADR Adverse drug reaction FFPE Formalin-fixed paraffin-embedded NSTI Necrotizing soft tissue infection ROC Receiver operative characteristics
Falco Hietbrink [email protected] Marijke R. van Dijk [email protected] 1
2
Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
Introduction Early diagnosis and immediate radical surgical treatment are vital for reducing the mortality rate of necrotizing soft tissue infections (NSTIs) [1–3]. NSTIs are notorious for
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World J Surg
being difficult to diagnose based on clinical symptoms, resulting in high rates of misdiagnosis and treatment delay [4, 5]. To resolve this problem, the approach using triple diagnostics (diagnosis based on macroscopic, histopathologic and microbiologic findings) has been proposed for ambivalent macroscopic cases [6]. The intra-operative evaluation of frozen sections and Gram stains enables identification of microsc
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