It’s 7:30 am and you’re assessing your workload for the day and the phone rings
“We have a frozen.”
In my early attending days, frozen sections felt like my worst nightmare. There’s a reason I’m not an emergency medicine physician. I’m not a big fan of surprises, time constraints, or high stress situations. However, over the years, through developing some basic principles and the confidence to create boundaries around a process, I’ve grown to really enjoy the diagnostic challenge and opportunity to interact with surgeons.
The goal of a frozen section is to guide real-time intraoperative management. Always keep this goal in mind. Here is my approach to reviewing frozen sections to 1) provide what the surgeon needs and 2) stay calm, collected and confident.
The pregame
As mentioned, I don’t like surprises. The days that I’m on call I review the OR schedule either the night before or morning of service. This mostly allows me to anticipate what I might encounter as well as to briefly review any clinical history.
Take your time
The College of American Pathologists recommends a frozen section turn around time of 20 minutes or less for single block specimens. Given that the goal is to guide the surgery, it is very important to be efficient but this doesn’t mean that you need to rush. You especially don’t need to rush if someone is standing over your shoulder demanding a read. Review any relevant clinical history, review the gross specimen, and take your time to thoroughly review the slide(s).
What is the clinical question?
Frozen sections are sent at critical decision points during surgery. Before you review the slides, ask yourself what information does the surgeon need to make this decision? What is the margin status – do we need to resect more tissue? Is tumor present – are we in the lesion of interest? Is this a parathyroid? Is the lymph node positive for tumor – do we need to do an axillary dissection?
Review the gross specimen
Don’t neglect the gross specimen. It can provide valuable information. How close is the tumor to the margin of interest? Does the lymph node consistency vary? Do you need to reserve some of the specimen or should it all be processed for frozen? Do any ancillary studies need to be done (e.g. flow cytometry)?
Give just enough, but not too much
Many surgeons are eager to know it all, understandably. It’s important for all involved to accept that frozen sections are limited by limited sampling, artifact, and a single stain (H&E is your best friend, but IHC stains are certainly helpful). For example, if a surgeon sends a frozen for an epidural mass, she just needs to know if neoplasm is present. You can provide a differential, if asked, but it’s best to not be definitive until the remainder of the specimen and permanent sections can be reviewed.
Phone a friend
If you are unsure or wavering and work with other pathologists, reach out to someone else for assistance. In very challenging cases, especially when you don’t feel that you can be definitive, it can be helpful to get a second opinion. For example, I once had a case of a planned total gastrectomy for a young patient with signet ring cell carcinoma on biopsy. Intraoperatively, the surgeon identified multiple subcentimeter nodules on the peritoneum which he sent for frozen section. The specimens consisted of multiple 0.2 cm fragments of soft tissue with scattered atypical cells. In the context of the clinical history, the cells were concerning but there just weren’t enough of them for me to feel I could definitively call malignancy, especially as signet ring cell carcinoma can be an IHC-diagnosis in these situations. The critical decision point for the surgeon was to proceed with resection or abort the surgery and proceed with chemotherapy. Given the stakes, I decided to show several colleagues and none of us could be definitive. While it feels unsatisfying, if the tissue doesn’t lend itself to a definitive diagnosis then it is 100% acceptable to call something “atypical, defer to permanent.”
Report the frozen – keep it clear and concise
Most labs have a system of reporting frozen section diagnoses by phone. For complicated cases, I will often go to the OR to discuss it face-to-face with the surgeon. When you report the diagnosis, be sure that you announce who you are and verify the patient demographic information before relaying the diagnosis. Surgeons are often running multiple ORs at once or similar cases are run in different rooms, so it’s critical to make sure you’re reporting on the right patient. Be clear and concise. Too much information can often be lost in translation in the hustle and bustle of the room.
Document the frozen
You will need to document the frozen section – generally, the information documented includes patient name, medical record number, specimen, diagnosis, turnaround time and pathologist name. Each institution will vary in who records this information but make sure that you’re aware of your responsibilities.
When you have a system in place, frozen sections can feel less daunting and actually be kind of fun.
Do you enjoy frozen sections? What are your tips?