Frozen Section Diagnosis
Frozen Section Diagnosis
malignant benign
await staging curettage
and chemo
Grade 3 histology 3X
Adnexal involvement 4x
Hysterectomy examination
• Check previous histology
• Open 3 and 9 o’clock
• Breadloaf through gross lesion all the way
to serosa
• Sample deepest approach, and upper canal
if lesion is low
• Accuracy 80% to 96%
• Usual problem is undergrading
Case 15
• 34 year old woman presents with
intermittent acute abdomen and large
ovarian mass. Contralateral ovary was
removed 10 years previously for a benign
cystic teratoma
Ovarian mucinous
adenocarcinoma
Frozen Section Diagnosis,
Indications and Pitfalls
1. Pediatric cases
2. Lung and pleura
Aliya N. Husain, MD
University of Chicago
Frozen section is an answer
• So, what is the question?
Purpose of frozen section
• Primary diagnosis
• Benign versus malignant
• Margins
• Lymph node status
• Extent of disease
• Triage of tissue
Pediatric frozen sections
• Hirschsprung’s disease
• Lymph nodes
• Tumors
– Primary
– Metastatic
• Brain and cord
• Bone lesions
• Transplant related
Case 1
• One month old male with Hirschsprung’s
disease diagnosed clinically and on suction
rectal biopsy, now undergoing endorectal
pull through.
Case 1 - FS1: colonic wall
FS1: colonic wall
Case 1 - FS1: colonic wall
FS1: colonic wall
Case 1 - FS1: colonic wall
FS1: colonic wall
Diagnosis: No ganglion cells
Case 1 - FS2: biopsy #2
FS2: biopsy #2
Case 1 - FS2: biopsy #2
FS2: biopsy #2
FS2: biopsy
Case 1 - FS2:#2
biopsy #2
FS2: biopsy #2biopsy #2
Case 1 - FS2:
Diagnosis: Ganglion
cells present (appear
normal)
Case 2
• 16 day-old male with Hirschsprung’s
disease diagnosed clinically and on suction
rectal biopsy, now undergoing endorectal
pull through. Specimen #1was submitted for
frozen section, labeled “rectum”.
Case 2 - FS: rectum
Case 2 - FS: rectum
Case 2 - FS: rectum
Case 2 - FS: rectum
Diagnosis: Ganglion
cells present
Frozen section for
Hirschsprung’s disease
• Orientation of specimen
BREAST
SENTINEL LYMPH NODE (BREAST)
KIDNEY
PROSTATE
URINARY BLADDER
Three years later two masses were detected in the same (left) breast. At
the time of excision, a frozen section was requested. The treatment
decision was that if the lesion were malignant, a mastectomy would be
undertaken immediately. The images are from one of the masses (both
were identical), a 1.2 cm. firm, stellate, white lesion.
DIAGNOSIS CASE 1: DEFERRED - INFLAMMATORY
CD68 AE1/AE3
5-YEAR SURVIVAL: TUMOR SIZE AND AXILLARY NODES
MEMORIAL HOSPITAL 1935-1942
1355 OPERABLE CASES
A 62 year old woman with a previous needle core biopsy of infiltrating ductal
carcinoma of the right breast. She presents for sentinel node biopsy. A frozen
section is requested with the treatment intent to complete the axillary
dissection if metastatic tumor is detected. These images are from a 1.0 cm.
lymph node which was grossly negative.
DIAGNOSIS CASE 2: METASTATIC ADENOCARCINOMA
SENTINEL LYMPH NODE
A 74 year old male with a left renal mass. Prior work-up included
endoscopies and percutaneous biopsies and aspirations. The imaging
studies done at an outside hospital were suspicious for a renal tumor. The
patient underwent a laparascopic radical nephrectomy. The dissection
was difficult due to local adhesions and scarring.
A frozen section was requested with the treatment decision that if the
lesion were a urothelial carcinoma a completion ureterectomy would be
done. The images are from a dominant poorly circumscribed 1.3 cm.
renal mass, focally friable bright orange and reddish-blue which focally
involved the calyceal mucosa. Multiple similar smaller (1-8 mm) lesions
were scattered through the renal parenchyma.
DIAGNOSIS CASE 3: XANTHOGRANULOMATOUS
PYELONEPHRITIS
CASE 4
A 67 year old woman with a masses in the upper and lower poles of the left
kidney as well as a mass on the contralateral side. In order to maximally
preserve renal function, partial nephrectomies of these masses were done.
The upper pole mass was a 3.0 cm. solid clear cell renal adenocarcinoma.
The images are from the lower pole mass, a 1.3 cm. cystic lesion with
slightly yellowish walls. Frozen section was requested for margins if the
lesion were malignant.
DIAGNOSIS CASE 4
ABSOLUTE
• LOCALLY ADVANCED DISEASE (T3c)
• PALPABLE DISEASE AT THE APEX
• ANY GLEASON 5
• PSA> 20 ng/ml
• PREOPERATIVE IMPOTENCE
RELATIVE
• INTRAOPERATIVE MOBILIZATION DIFFICULTY
• PALPABLE LOCALIZED DISEASE NOT INVOLVING APEX
• PSA BETWEEN 10 AND 20 ng/ml
• GREATER THAN 50% GLEASON 4 ON BIOPSY
• PERINEURAL INVASION
• PREOPERATIVE TUMOR LOAD (3 SEXTANT CORES INVOLVED FROM
SAME SIDE)
CASE 6
A 57 year old man with a previous history within the last month of a right
nephroureterectomy for a 2.2 cm urothelial carcinoma. The serum PSA
was 29.37 ng/ml. Needle biopsies of the prostate from an outside hospital
disclosed adenocarcinoma, Gleason 7 (4+3) with small foci of Gleason
pattern 5 (< 10%) occupying 60% of the samples (each side). The patient
was taken to surgery with the intent of doing a robotic assisted
laparoscopic radical prostatectomy. The pelvic lymph nodes were
sampled first. The images are from a left pelvic lymph node.
DIAGNOSIS CASE 6: METASTATIC ADENOCARCINOMA
PELVIC LYMPHADENECTOMY
• COMPLICATIONS
– INTROPERATIVE INJURY TO OBTURATOR NERVES AND VESSELS
– LYMPHOCELE
– LYMPHOCUTANEOUS FISTULA
– CHRONIC LOWER EXTREMITY/GENITAL EDEMA
• FROZEN SECTION
– SAMPLING ERROR
– NO STANDARDIZATION OF EXAMINATION
– FALSE NEGATIVE RATE HIGH
– COST
• UNNECESSARY FOR LOW RISK PATIENTS
– LIMITED STAGE DISEASE (T2 OR LESS)
– SERUM PSA <10 ng/ml
– GLEASON 6 or less
CASE 7
A 74 year old man with an episode of gross hematuria and found to have
an invasive bladder cancer at an outside institution. There was a heavy
smoking history (57 pack years). Multiple medical problems included
vascular disease, colon resection for cancer, lung cancer and a urothelial
cancer of one kidney. He undergoes cystectomy. The images are from the
frozen sections requested on the ureteral margins.
DIAGNOSIS CASE 7: POSITIVE URETERAL MARGIN (CIS)
UROTHELIAL FROZEN SECTION
• DIFFUSE CIS
• PROSTATIC DUCT INVOLVEMENT
• GROSS URETERAL INFILTRATION DISCOVERED AT SURGERY
• MOST FROZEN SECTION REQUESTS UNNECESSARY