Frozen Section Pathology

Breast cancer (BC) remains a significant public health issue in both developed and developing countries due to its high prevalence. In developed nations, the incidence of BC is rapidly rising, posing challenges to countries with limited resources. According to the 2020 global statistics from the official Global Cancer Observatory (GCO), around 2,261,419 new cases of BC were reported, and 684,996 individuals died from BC.

Various factors influence the treatment of BC. The gold standard treatment for most early-stage BC patients is breast-conserving surgery (BCS) followed by postoperative radiotherapy. This approach provides similar survival rates and a better quality of life, including body image, physical functioning, emotional well-being, social functioning, pain, and overall health perceptions, when compared to mastectomy patients.

During BCS, surgeons often need immediate pathological information and may ask for an intra-operative consultation on the excised tissue. These results significantly affect the surgeon’s treatment decisions. The rapid Frozen Section pathology (FS) method is used as an intraoperative pathological diagnostic tool, originally introduced by Welchin in 1891 and further developed by Wilson in 1905. (1)

What is the frozen section in histopathology?

During a frozen section pathology outline, a surgeon quickly examines a tissue sample from a suspicious mass while the patient is still in surgery. This rapid biopsy, also known as a cryosection, helps the surgeon make immediate diagnostic decisions.

Frozen section pathology is performed during surgery on patients with breast cancer under anesthesia. While patients are asleep, the surgeon extracts tissue from a suspicious breast mass, and sends it to a pathologist present in the operating theater. The pathologist freezes the tissue using liquid nitrogen, prepares it, and then applies special staining solutions in order to examine it under a microscope.

The diagnosis from the frozen pathology is communicated to the surgeon while the patient is still under general anesthesia. Though this process prolongs the surgery, it offers the surgeon an initial diagnosis of whether a suspicious mass is benign or cancerous. If benign, the surgery can be less invasive. If the tissue is cancerous, further tissue removal is needed to determine the extent of the cancer, providing valuable information for selecting postoperative treatment. (2)

Frozen section biopsy procedure

Biopsies involve the removal of a small part of a mass suspected of containing tumors, which is then examined under a microscope by doctors to determine the likelihood of cancer, infection, or other illnesses.

When an oncologist suspects cancer in a patient, a sample of tissue is taken or extracted from the body for a biopsy to ascertain whether the cancer is benign or malignant.

For breast cancer cases, a common procedure known as frozen section biopsy is often conducted to ascertain whether the tissue is cancerous (malignant) or non-cancerous (benign). This procedure is also referred to as intra-operative frozen section.

How is frozen section biopsy performed?

During the frozen section procedure, a sample of tissue is taken from the suspected area and sent to a lab for analysis. The tissue is moved from the operating room to the frozen tissue lab during the procedure. In the lab, the sample is quickly frozen using a freezing microtome machine. A very thin slice of the frozen tissue is then cut, mounted on a slide, and examined under a microscope. The pathologist shares the results with the surgeon in the operating room, allowing for immediate adjustments to the operation and avoiding the need for additional procedures. Biopsying breast tissue using a frozen section can yield precise resultsand offer several advantages.

Importance of Properly Examining Frozen Pathology

When obtaining a tissue specimen from a patient through biopsy or surgery, it is standard practice for a pathologist to evaluate the specimen the day after it has been properly fixed in formalin. However, there are instances when surgeons require urgent pathological information and request an intra-operative consultation for real-time assessment of the tissue being removed.

An intra-operative consultation involves examining the specimen while the patient is under anesthesia on the operating table. This process includes visual inspection and, for larger specimens, some dissection. Depending on the surgeon’s query and the pathologist’s assessment, a frozen section (FS) may be conducted on the specimen and examined under a microscope. The examination report is promptly conveyed to the operating surgeon via telephone or intercom, and the result significantly influences the surgeon’s intra-operative decision.

Conducting a frozen section (FS) may be one of the most critical procedures for the pathologist. It is a demanding procedure that requires the pathologist to make quick and accurate decisions under pressure, relying on experience, judgment, and specialized knowledge of clinical medicine. The pathologist must also be mindful of the method’s limitations, as the patient’s well-being is often greatly impacted by their report.

Similarly, the operating surgeon should be aware of the limitations of FS. The surgeon needs to plan the FS examination in advance and consider whether the results will impact the surgical procedure. If not, the FS examination is unnecessary.

Frozen Section Pathology Advantages

An analysis of tissue taken during surgery and quickly frozen is crucial because most pathologists and oncologists rely on it to determine the spread of cancer.
Rapid frozen pathology analysis is a time-saver during surgery, eliminating the need for further operations and allowing the surgeon to obtain tissue samples promptly. It also requires only a small amount of tissue for an accurate diagnosis.
Many surgeons prefer this method due to its expediency, enabling swift treatment. If cancerous tissue is found, the affected breast can be promptly treated or removed.
If the tissue is found to be non-cancerous, there is no need for further action.
Results from a frozen section biopsy analysis are quick, taking less than 20 minutes compared to other methods.
Frozen pathology analysis can decrease the need for additional surgeries in breast conservation procedures for breast cancer treatment. (3)

Frozen Section Pathology Disadvantages

he frozen section pathology uses comes with various limitations, and different institutions have reported diverse experiences in its use for diagnosing tumor involvement.

Employing this method helps decrease the rate of reoperations and lowers the incidence of positive surgical margins. However, the latter encompasses suboptimal tissue preparation due to histological frozen artifact, cautery artifact, and/or inadequate sampling, any of which could lead to an indeterminate or inaccurate diagnosis. Although the diagnostic precision of FS pathology is not flawless, it also relies on the knowledge and experience of the pathologist. Additional limitations of this method include prolonging the duration of the operation, an increased likelihood of false negatives in patients who have undergone new joint therapy, unreliability in specific BC subtypes such as invasive lobular cancer or ductal carcinoma in situ (DCIS), and contribute to higher health care costs. Furthermore, it is crucial to evaluate the clinical application of FS pathology and its limitations, particularly given the increasing use of FS in many regions of the world for BC. (4)

New Techniques instead of Frozen Pathology

As mentioned before, frozen pathology has limitations and errors, and the reports indicate that borderline tumors are not easily detected by the frozen section in pathology. This is a cause for concern because borderline cancer may not be identified. Therefore, it cannot be the sole technique relied upon. However, other methods should be used by oncologists and pathologists to test the suspected tissue.

Some modern methods and equipment that are less invasive and provide more accurate diagnosis can potentially replace the invasive method of frozen pathology, including:

Cancer Diagnostic Probe (CDP)

Breast-Conserving Surgery (BCS) is conducted with the objective of removing cancerous tumors while ensuring adequate margins to obviate the requirement for further surgical interventions. However, the presence of cancerous cells at the edges of the excised tissue poses an elevated risk of cancer recurrence. The Cancer Diagnostic Probe (CDP) is employed for immediate assessment of the margins of the surgical cavity subsequent to tumor removal. The CDP is specifically designed to identify high-risk pre-cancer/cancer cells in cavity side margins and detect cancerous cells in the lymph nodes of breast cancer diagnostic patients in real-time, in conjunction with frozen-section and permanent pathologies. This real-time detection capability serves to validate the absence of residual cancerous cells, potentially reducing the necessity for supplementary surgeries and alleviating emotional and physical burdens on patients.

Gamma Probe

The high prevalence of breast cancer among women necessitates frequent breast surgery procedures to excise malignant tumors. The identification and removal of cancerous lymph nodes (sentinel nodes) are pivotal in curbing the spread of cancer in patients. Presently, a range of methods with varying degrees of accuracy are available for sentinel node detection. The Gamma Probe, widely utilized by surgeons due to its user-friendliness and capacity to pinpoint and localize sentinel lymph nodes in breast cancer and certain male cancers, stands out among these methods. The Gamma Probe is a compact, exceptionally sensitive tool engineered to accurately detect and precisely locate sentinel nodes. Manufacturers of the Gamma Probe have designed it to be portable and to deliver high sensitivity for reliable sentinel node detection.

Impedimetric Tumor Detection System

The limitations of sonography in identifying breast mass abnormalities often leads to delayed patient treatment and necessary biopsies. In response to these challenges, the Impedimetric Tumor Detection System (ITDS) has been developed. This advanced technology incorporates a specially engineered probe that is guided into the patient’s body using ultrasound and swiftly withdrawn, providing immediate test results. ITDS proves particularly beneficial for younger patients with dense breast tissue, particularly those with BIRADS-3 masses that are difficult to assess using mammography. Additionally, individuals with BIRADS-3 masses and a family history of breast cancer can derive significant advantages from this system. The device also plays a crucial role in distinguishing simple fibroadenomas from complex fibroadenomas and phyllodes tumors.

Hospitech Cancer Care Innovations for Breast Cancer

Hospitech Cancer Care Innovations Company is at the forefront of revolutionizing breast cancer diagnosis through its innovative suite of devices, including the Cancer Diagnostic Probe (CDP), Impedimetric Tumor Detection System (ITDS), and Gamma Probe. These advanced technologies are specifically engineered to improve the efficacy of cancer detection and treatment. Supported by robust research, scholarly articles, and patents, these tools yield precise outcomes for early diagnosis and enhanced patient prognosis. The company prides itself on its dedicated team and unwavering commitment to making a substantial impact in the healthcare industry’s battle against cancer.

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