Intraoperative Consultation E-Book : a Volume in the Series: Foundations in Diagnostic Pathology

This new volume in the Foundations in Diagnostic Pathology Series is a highly practical and easy-to-use medical reference book for effectively approaching intraoperative consultations. Ideal for practicing pathologists and their surgical colleagues, it describes the most efficient way to handle specimens , how to focus on the differential diagnosis , and the best methods for reporting findings. Take an integrated approach to intraoperative consultation with chapters that have been coauthored by both pathologists and surgeons. Grasp today's most up-to-date information for the pathologist and surgical team with a templated format that includes techniques of specimen collection, differential diagnosis, additional ancillary studies, terminology, and proper reporting. Effectively perform frozen sections with help from high-quality color illustrations, photomicrographs, and gross photography. 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Front Cover Inside Front Cover Other books in this series: Intraoperative Consultation: A Volume in the Series Foundations in Diagnostic Pathology Copyright Contributors Foreword Preface Contents Chapter 1: General Guidelines for Intraoperative Consultations with Frozen Section HISTORICAL BACKGROUND SUGGESTIONS FOR SUCCESSFUL INTRAOPERATIVE CONSULTATIONS SUGGESTED “NO-NOS” DURING INTRAOPERATIVE CONSULTATIONS FROZEN SECTION INDICATIONS COMMUNICATION DURING INTRAOPERATIVE CONSULTATIONS Turnaround Time Discrepancies SUGGESTED READING Chapter 2: Guide to the Preparation of Intraoperative Touch Preparations and Other Cytologic Preparations INTRODUCTION ADVANTAGES LIMITATIONS PREPARATION TECHNIQUES STAINING GENERAL DIAGNOSTIC CONSIDERATIONS SPECIFIC SITE CONSIDERATIONS Lymph Nodes Thyroid Pancreas Lung Liver Serosal Nodules Gynecologic Bone and Soft Tissue SUGGESTED READING Chapter 3: Guide to the Preparation of Frozen Sections INTRODUCTION BASIC EQUIPMENT Workstation: Cutting Board and Basic Supplies The Cryostat PERFORMANCE OF IOC WITH FROZEN SECTION Review Surgical Schedule and Clinical History of Patients who are Likely to Require IOC Mechanisms to Retrieve Pathology Slides from Previous Surgeries in Selected Cases Gross Evaluation and Selection of Appropriate Samples for Frozen Section Tissue Triage Embedding Tissues Cutting Frozen Sections Fixing and Staining Frozen Sections Troubleshooting Problems During the Frozen Section Procedure Additional Intraoperative Procedure Methods Safety Quality Control and Quality Assurance Process Chapter 4: Intraoperative Consultation During Neurosurgery SCENARIO #1 Nonenhancing Brain Lesions SCENARIO #2 Enhancing Intraaxial Lesions without Surrounding Edema SCENARIO #3 Enhancing Intraaxial Lesions with Edema SCENARIO #4 Enhancing Mass in Meninges SCENARIO #5 Lesion of the Skull Base SCENARIO #6 L esion in the Proximity of the Third and Lateral Ventricles SCENARIO #10 Mass Lesions in the Posterior Fossa SCENARIO #11 Spinal/Paraspinal Mass SCENARIO #12 Enhancing Lesion within the Confines of Previously Resected Glioma ADDITIONAL GENERAL CONSIDERATION Chapter 5: Intraoperative Consultations During Skin Surgery INTRODUCTION INDICATIONS AND CONTRAINDICATIONS FOR FROZEN SECTIONS Margin Assessment Gross Examination SPECIFIC DIAGNOSTIC CONSIDERATIONS Basal Cell Carcinoma (BCC) Pitfalls in the Frozen Section Diagnosis of BCC ( Table 5-4) Squamous Cell Carcinoma (SCC) Pitfalls in the Diagnosis of SCC Metastatic Tumors to the Skin Pitfalls in the Diagnosis of Metastatic Tumors TOXIC EPIDERMAL NECROLYSIS AND STAPHYLOCOCCAL SCALDED SKIN SYNDROME SUGGESTED READING Chapter 6: Intraoperative Consultation of Thyroid and Parathyroid Lesions INTRAOPERATIVE CONSULTATION OF THYROID LESIONS General Clinical Introduction Indications for IOC with Frozen Section During Thyroid Surgery Limitations and Contraindications Specimen Types and Handling During IOC Intraoperative Gross Evaluation of Thyroid Lesions Intraoperative Cytologic Evaluation of Thyroid Lesions Frozen Section Evaluation Evaluation of Solitary Encapsulated Follicular Nodule Intraoperative Evaluation of a Nonencapsulated Infiltrative Thyroid Mass Intraoperative Evaluation of Multinodular Goiter with One Dominant Nodule Intraoperative Evaluation of Locally Invasive Tumors/Masses Lacking a Dissection Tissue Plane Intraoperative Evaluation of an Extrathyroidal Nodule Intraoperative Evaluation of Capsular and/or Vascular Invasion in an Encapsulated Follicular Lesion DIAGNOSTIC ACCURACY OF THE INTRAOPERATIVE DIAGNOSIS OF THYROID LESIONS AND POTENTIAL PITFALLS Underdiagnosis or Overdiagnosis of PTC due to Freezing Artifacts Overdiagnosis of Minimally Invasive Follicular Carcinoma of the Thyroid in the Presence of Pseudoinvasion an ... Differential Diagnosis of PTC Follicular Variant of Papillary Carcinoma vs . Follicular Adenoma Papillary Thyroid Carcinoma vs . Hyalinizing Trabecular Adenoma INTRAOPERATIVE CONSULTATION OF PARATHYROID LESIONS General Clinical Introduction Specimen Types and Handling During Parathyroid IOC Gross Examination Cytologic Evaluation Frozen Section Evaluation Parathyroid vs . Other Tissues Normal Parathyroid vs . Abnormal Gland Adenoma vs . Hyperplasia Adenoma vs . Carcinoma Intraoperative Quick Assay of Parathyroid Hormone Diagnostic Problems During Parathyroid IOC Normal vs . Abnormal Parathyroid Thyroid vs . Parathyroid Other Diagnostic Problems Chapter 7: Intraoperative Consultation During ENT and Laryngeal Surgery INDICATIONS OF IOC WITH FROZEN SECTION DURING ENT SURGERY Intraoperative Diagnosis of Malignancy Evaluation of Surgical Margins CONTRAINDICATIONS TO FROZEN SECTION DURING ENT SURGERY Limitations of Frozen Section Sources of Error During IOC with Frozen Section INTRAOPERATIVE EVALUATION OF BIOPSIES PERFORMED PRIOR TO A MAJOR RESECTION IOC DURING SURGERY FOR ORAL CAVITY LESIONS Frozen Section of Oral Cavity Biopsies Frozen Sections Evaluation of Resection Margins From Oral Cavity Resection Specimens Inking and Sectioning of Resection Margins D iagnostic P roblems with the E valuation of M argins D uring the R esection of O ral C avity S quamous L esions TREATMENT DIFFERENCES BASED UPON FROZEN SECTION RESULTS: SQUAMOUS LESIONS IOC DURING SURGERY FOR FLOOR-OF-MOUTH LESIONS IOC DURING SURGERY FOR TONGUE, OROPHARYNGEAL AND/OR TONSILLAR LESIONS IOC DURING SURGERY FOR THE DIAGNOSIS AND TREATMENT OF NASOPHARYNGEAL LESIONS IOC DURING SURGERY FOR THE DIAGNOSIS OR RESECTION HYPOPHARYNGEAL AND LARYNGEAL LESIONS IOC DURING PAROTIDECTOMY IOC DURING LYMPH NODE BIOPSIES AND RADICAL NECK DISSECTION Sentinel Lymph Node Biopsy REFERENCES Chapter 8: Intraoperative Consultation During Salivary Gland Surgery INTRODUCTION INITIAL APPROACH TO INTRAOPERATIVE EVALUATION APPROACH TO GROSS EVALUATION AND TISSUE SAMPLING Preparation of Histologic Sections Microscopic Approach Tumor Pattern Architectural Pattern Cytoarchitecture CYTOMORPHOLOGY STROMA SPECIFIC DIAGNOSES Pleomorphic Adenoma Warthin Tumor Mucoepidermoid Carcinoma Acinic Cell Carcinoma Polymorphous Low -Grade Adenocarcinoma Epithelial -Myoepithelial Carcinoma Adenoid Cystic Carcinoma Carcinoma Ex Pleomorphic Adenoma MANAGEABLE DIAGNOSES Overlapping Cytomorpholocic Alteration CONCLUSION Chapter 9: Intraoperative Consultation in Frozen Section of Intrathoracic Lesions FROZEN SECTION OF LYMPH NODES IN PATIENTS UNDERGOING MEDIASTINOSCOPY MEDIASTINOSCOPY FOR STAGING OF A LUNG MASS PRESUMED TO BE A NON–SMALL CELL CARCINOMA OF THE LUNG MEDIASTINOSCOPY FOR ADENOPATHY IN A PATIENT WITH NO LUNG MASS LESION ACCURACY OF MEDIASTINOSCOPY: SAMPLING ISSUES INTRAOPERATIVE EVALUATION OF MEDIASTINAL LYMPH NODES OBTAINED WITH EBUS-TBNA INTRAOPERATIVE EVALUATION OF LUNG WEDGE BIOPSIES FROM PATIENTS WITH ACUTE NONNEOPLASTIC CONDITIONS INTRAOPERATIVE EVALUATION OF LUNG WEDGE BIOPSIES FROM PATIENTS WITH CHRONIC DIFFUSE LUNG DISEASES INTRAOPERATIVE EVALUATION OF PATIENTS WITH PULMONARY GROUND-GLASS OPACITIES: SAMPLING AND OTHER ISSUES INTRAOPERATIVE EVALUATION OF WEDGE BIOPSIES FOR PULMONARY MASS LESIONS Organizing Pneumonia with Reactive Pneumocyte Atypia vs. Non–small Cell Carcinoma Granulomatous Pneumonia vs. Carcinoma Carcinoid Tumor vs. Non–small Cell Carcinoma of the Lung Primary Nsclc vs. Metastatic Carcinomas of Breast, Colonic, Renal, and Other Origin EVALUATION OF RESECTION MARGINS IN LUNG SPECIMENS Evaluation of Parenchymal Resection Margin in Patients Undergoing Sublobar Resection of a Lung Nodule INTRAOPERATIVE EVALUATION OF BRONCHIAL RESECTION MARGINS IN LOBECTOMY, PNEUMONECTOMY, AND SLEEVE RESECTION SPECIMENS TRIAGE OF LUNG TISSUES FOR MOLECULAR AND OTHER ANCILLARY STUDIES INTRAOPERATIVE EVALUATION OF PLEURAL BIOPSIES Reactive Mesothelial Hyperplasia vs. Metastatic Carcinoma Malignant Mesothelioma vs. Carcinoma P leuritis vs. L ymphoma INTRAOPERATIVE EVALUATION OF RESECTION MARGINS IN CHEST WALL RESECTION SPECIMENS INTRAOPERATIVE EVALUATION OF MEDIASTINAL LESIONS INTRAOPERATIVE EVALUATION OF BIOPSIES FROM MEDIASTINAL LESIONS HANDLING OF THYMECTOMY SPECIMENS EVALUATION OF THYROID AND PARATHYROID LESIONS EVALUATION OF POSTERIOR MEDIASTINAL LESIONS Chapter 10: Intraoperative Consultation During Gastric and Esophageal Surgery INTRODUCTION IOC DURING ESOPHAGEAL SURGERY Esophagectomy for Cancer Assessing Cancer Extent at Esophagectomy Margin Assessment at Esophagectomy for Adenocarcinoma Margin Assessment at Esophagectomy for Squamous Cell Carcinoma Radial Margin Assessment at Esophagectomy Errors and Diagnostic Difficulties in Frozen Sections of Esophagectomy Margins Diagnosis of Esophageal Mucosal Lesions or Masses Without Preoperative Diagnosis Esophageal Surgery for Mural Tumors Diagnosis of Esophageal Mural Lesions or Masses Without Preoperative Diagnosis Diagnosis of Esophageal Mesenchymal Tumors Esophagoscopy IOC DURING GASTRIC SURGERY Gastrectomy for Cancer Assessing Cancer Extent at Gastrectomy Margin Assessment at Gastrectomy for Gastric Cancer IOC of Gastric Gastrointestinal Stromal Tumors Tissue Diagnosis of Gastric Gastrointestinal Stromal Tumors Margin Assessment of Gastric Gastrointestinal Stromal Tumors Surgery for Gastric Ulcer Surgery for Free Gastric Perforation Gastric Surgery for M ural Lesion Gastric Surgery for Carcinoid Tumor Conclusions Chapter 11: Intraoperative Consultation During Colonic and Rectal Surgery INTRODUCTION DETERMINATION OF THE EXTENT OF DISEASE Frozen Section of Peritoneal N odules/Implants to Rule out Metastasis Frozen Section of Incidental Liver Nodules to Rule Out Metastasis Frozen Section to Look for Ganglion Cells for Hirschsprung Disease DETERMINATION OF THE ADEQUACY OF TUMOR RESECTION (MARGIN EVALUATION) IOC of Distal Margin for Rectal Adenocarcinoma IOC of R adial M argin for R ectal A denocarcinoma DETERMINATION OF THE BENIGN AND MALIGNANT NATURE OF UNUSUAL OR UNEXPECTED INTRAOPERATIVE FINDINGS Unusual or Unexpected Findings During Surgery for IBD, Diverticulitis, and Ischemic Bowel Submucosal or Mural Lesions that do not have a Preoperative Diagnosis Chapter 12: Intraoperative Consultation During Intestinal, Appendiceal, and Proximal Colonic Surgery, Including Neuroendocrine INTRODUCTION INTRAOPERATIVE CONSULTATION OF INTESTINAL STRICTURE/OBSTRUCTION Distinguishing Neoplastic from Common Nonneoplastic causes of Intestinal Stricture/Obstruction Neoplasticcauses of Stricture/Obstruction Nonneoplastic causes of Stricture/Obstruction INTRAOPERATIVE CONSULTATION OF MUCOSAL POLYPS INTRAOPERATIVE CONSULTATION OF SUBMUCOSAL MASSES Pancreatic Heterotopia Neuroendocrine Tumors Lymphomas Metastatic Masses or Lesions IOC FOR INTRAMURAL MASSES OF MESENCHYMAL ORIGIN IOC OF A DILATED APPENDIX AND PSEUDOMYXOMA PERITONEI Dilated Appendix Pseudomyxoma Peritonei Chapter 13: Intraoperative Consultation During Pancreato-Biliary Surgery INTRODUCTION IDENTIFICATION OF THE MARGINS AND ORIENTATION OF THE SPECIMEN Pancreaticoduodenectomy (Whipple Procedure) Orientation Difficulties /Caveats in Identification of the Margins Distal Pancreatectomy Central Pancreatectomy Ampullectomy Specimens Bile Duct Resection Specimens Local Pancreatic Resection and Enucleation SECTIONING OF THE MARGINS ( Table 13-3) FROZEN SECTION EVALUATION OF THE MARGINS Low-Power Assessment High-Power Assessment Bile Duct Margin Assessment Frozen Sections for Intraductal Papillary Mucinous Neoplasms (IPMN) of the Pancreas INTRAOPERATIVE/FROZEN SECTION EVALUATION OF A MASS LESION IN THE PANCREAS Clinical History and Preoperative Diagnosis Intraoperative Handling of the Pancreatectomy Specimens Gross Examination ( Tables 13-6 and 13-7) Microscopic Examination of A Mass Lesion ( Tables 13-6 and 13-7) INTRAOPERATIVE/FROZEN SECTION FOR NESIDIOBLASTOSIS Management Strategy Based on Intraoperative Results Chapter 14: Intraoperative Consultation During Liver Surgery INTRODUCTION EVALUATION OF SUSPECTED METASTATIC LIVER LESIONS, OFTEN ON THE HEPATIC CAPSULE Differential Diagnosis: Enlarged Inflammatory Portal Tracts Bile Duct Hamartoma Bile Duct Adenoma Benign Biliary Lesion vs. Metastasis at Frozen Section EVALUATION OF SURGICAL MARGINS IN ONCOLOGIC RESECTIONS AT THE TIME OF PARTIAL HEPATECTOMY AND BILIARY RESECTIONS Bile Duct Margins LIVER TUMORS Differential Diagnosis Scenarios EVALUATION OF UNINVOLVED HEPATIC PARENCHYMA, INCLUDING DONOR LIVER DURING TRANSPLANTATION Presence and Extent of Steatosis Microvesicular Steatosis Assess Extent of Fibrosis in Patients With Underlying Viral Disease Incidental Nodules in Living Donors Found at Time of Harvesting Chapter 15: Intraoperative Consultation During Breast Surgery INTRAOPERATIVE CONSULTATION FOR SENTINEL LYMPH NODE Indication for F rozen S ection Qualified and Representative L ymph N ode S ections Interpretation of Frozen Section Results for SLN Pitfalls FROZEN SECTION OF NIPPLE FOR NIPPLE-SPARING MASTECTOMY Indications for Frozen Section Sampling for Frozen Section of Nipple -Areola Complex Interpretation of Frozen Section Results of NAC Pitfalls in the Interpretation of Frozen Section of NAC INTRAOPERATIVE DIAGNOSIS OF A BREAST LESION WITHOUT PRIOR DIAGNOSIS Indication of Frozen Section Sampling for Frozen Section of a Breast Mass Interpretation of Frozen Section for Breast Mass Pitfalls for the Interpretation of Frozen Section Results of Breast Mass ASSESSMENT OF MARGINS QUALITY CONTROL AND TROUBLESHOOTING OF FROZEN SECTIONS: Suggested Reading Chapter 16: Intraoperative Consultation During Urologic Surgery KIDNEY TUMOR/MASS Partial or Complete Nephrectomy for Renal Mass Identification and Characterization of Renal Mass Lesion Urothelial Versus Renal Primary Lymph Nodes to Rule Out Metastatic Disease URETER RESECTION FOR TUMOR Margins Evaluation of Mass Lesion BLADDER TUMOR/MASS Margins of Cystectomy, Partial and Radical Diagnosis of Mass Lymph Node or Metastatic Deposit PROSTATE GLAND FOR CANCER PENIS AND SCROTUM Margins Masses /Lesions Lymph Nodes TESTICULAR MASS Mass /Tumor Margins Lymph Nodes TESTICLE: INFERTILITY LYMPH NODES OR POSSIBLE METASTATIC DEPOSITS Chapter 17: Frozen Section in Gynecologic Pathology (Ovary, Fallopian Tube, and Peritoneum) OVARY: CLINICOPATHOLOGIC EXAMPLES Cystic or Predominantly Cystic Ovarian Lesions Differentiating the Type of Cyst by its Lining Cysts with Cytologic A typia, Solid Component, or Unusual Features: Borderline Tumor or Carcinoma Solid or Predominantly Solid Ovarian Lesions What can we Learn from the Gross Features of the Lesion ? Does the Lesion Involve Mainly the Ovary, or is it Centered in the Periovarian or Perifallopian Tube Reg ... Does the Lesion Involve the Ovarian Surface ? Differentiating Into Benign or Malignant Ovarian Lesion NONFUNCTIONAL OVARIAN LESIONS Surface Epithelial Tumors Differentiating Serous Borderline Tumor from Carcinoma Differentiating Low -Grade from High -Grade Serous Carcinoma Differentiating High-Grade Serous Carcinoma from Other Müllerian Carcinomas Differentiating Mucinous Borderline Tumor from Carcinoma Differentiating Other types of Borderline Tumor from Carcinoma Sex Cord -Stromal Tumors Stromal Tumors Germ Cell Tumors Mixed Patterns FUNCTIONAL VS. NONFUNCTIONAL OVARIAN LESIONS METASTATIC PROCESSES INVOLVING THE OVARIES FALLOPIAN TUBE Cystic or Predominantly Cystic Periovarian or Fallopian Tube Lesions Solid or Predominantly Solid Periovarian or Fallopian Tube Lesions PERITONEUM Cystic or Predominantly Cystic Peritoneal Lesions Solid or Predominantly Solid Peritoneal Lesions Chapter 18: Intraoperative Consultation During Gynecologic Pathology (Vagina, Vulva, Uterine Cervix, and Corpus) INTRAUTERINE VERSUS ECTOPIC PREGNANCY VULVA VAGINA UTERINE CERVIX UTERINE CORPUS Endometrium Myometrium LYMPH NODE SAMPLING INDICATIONS FOR INTRAOPERATIVE CONSULTATION HISTOLOGIC CONFIRMATION OF INTRAUTERINE PREGNANCY CHALLENGES IN THE DIAGNOSIS OF VULVAR CARCINOMA CHALLENGES IN THE DIAGNOSIS OF CERVICAL CARCINOMA Squamous Cell Carcinoma Adenocarcinoma INTRAOPERATIVE EVALUATION FOR ENDOMETRIAL CARCINOMA DIFFERENTIAL DIAGNOSIS OF MYOMETRIAL TUMORS Rapidly Growing “Fibroid ” Wormlike Growth Associated with Uterine “Fibroids ” MIMICS OF MALIGNANCY IN LYMPH NODES Chapter 19: Frozen Section Diagnosis in Transplantation Pathology INTRODUCTION FROZEN SECTION INTRAOPERATIVE CONSULTATION FOR DONOR ORGAN EVALUATION Indications and Clinical Considerations Contraindications for Donor Organ Frozen Section Consultation FROZEN SECTION CONSULTATION FOR ASSESSMENT OF DONOR KIDNEYS Macroscopic Examination of Donor Kidneys Donor Kidney Specimen Adequacy and Preparation FROZEN SECTION EVALUATION OF DONOR KIDNEYS Routine Assessment ADDITIONAL FINDINGS IN DONOR KIDNEY FROZEN SECTION BIOPSIES ( Table 19-6) Glomeruli Tubules Inflammation Tumors FROZEN SECTION CONSULTATION FOR ASSESSMENT OF DONOR LIVERS Macroscopic Examination of Donor Livers Donor Liver Specimen Adequacy and Preparation FROZEN SECTION EVALUATION OF DONOR LIVERS Routine Assessment Fibrosis and Architectural Changes Steatosis Necrosis ADDITIONAL FINDINGS IN DONOR LIVER FROZEN SECTION BIOPSIES Vascular Changes Pigments in Liver Discrete Lesions and Nodules Granulomas Bile Duct Adenoma von Meyenburg Complex Focal Nodular Hyperplasia Hepatocellular Adenoma Other Tumors FROZEN SECTION CONSULTATION FOR DONOR LESIONS FROM SITES OTHER THAN POTENTIAL TRANSPLANT ORGANS FROZEN SECTION CONSULTATION IN THE POSTTRANSPLANT SETTING Chapter 20: Intraoperative Consultation During Orthopedic Surgery BONE AND JOINTS Revision Arthroplasty Inflammatory Conditions Neoplastic Conditions SOFT TISSUE Chapter 21: Biospecimen Collection During Intraoperative Consultation INFRASTRUCTURE FOR BIOSPECIMEN COLLECTION Intraoperative Consultation as A Site for Collection Advantages of Tissue Collection in the IOC Suite THE BIOBANKING TEAM IN THE IOC The Role of the Pathologist Challenges to the Clinical Workflow Through Tissue Collection in the IOC THE LOGISTICS OF BIOBANKING OPERATIONS IN THE IOC Coordination of Tissue-Collection Locations Time Frame and Workflow of Collection Effects of Frozen Section Results on Tissue Collection Routine and Customized Biobanking Collections Longitudinal Specimen Collection BIOBANKING COMPONENTS AND RATIONALE FOR A CENTRALIZED INSTITUTIONAL TISSUE COLLECTION INFRASTRUCTURE Flexibility of Services Through A Modular Biobanking Structure Finding A Biobank Model that Meets Institutional Needs Biobanking Model with Centralized Specimen Collection Virtual Biobanking Models Centralized Database Centralized IT Infrastructure QUALITY CONTROL OF TISSUE AND DATA FROM BIOSPECIMENS Data Quality Obtaining and Recording Intraoperative Data for Biospecimens Quality of Biospecimens CONCLUSIONS Chapter 22: Intraoperative Consultation Quality Assurance IOC QUALITY ASSURANCE PLAN POLICIES AND PROCEDURES General Safety Patient Safety Communication with the Surgeon Optimal use of Frozen Section MONITORS Preanalytic Analytic Frozen Section–Permanent Section Discordance, Deferral, Appropriateness of Deferral Postanalytic Turnaround Time Customer Satisfaction Index Inside Back Cover This new volume in the Foundations in Diagnostic Pathology Series is a highly practical and easy-to-use medical reference book for effectively approaching intraoperative consultations. Ideal for practicing pathologists and their surgical colleagues, it describes the most efficient way to handle specimens , how to focus on the differential diagnosis , and the best methods for reporting findings. "I am utterly confident you will enjoy this edition and find innumerable pearls of diagnostic wisdom that will bolster your practice of intraoperative consultations." Foreword John R. Goldblum, Feb 2015