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Correlation of Intraoperative Frozen Section Report and Histopathological Diagnosis

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Correlation of Intraoperative Frozen Section Report and Histopathological Diagnosis Original Research Article Correlation of intraoperative frozen section report and histopathological diagnosis Hiral Samir Shah1, Meena Rajiv Daveshwar2*, Neema Ankur Rana3 1Tutor, 2Associate Professor,3Assistant Professor, Pathology Department, SSG Hospital and Medical College, Baroda- 390001. Gujarat, INDIA. Email: [email protected] Abstract Frozen section (FS) is an accurate and reliable test for intraoperative consultation. More accurate sampling plus better communication between pathologist and surgeon is recommended to help reducing the rate of discordant and deferral cases. Frozen section is subject to various limitations which both surgeon and pathologist should keep in mind when ordering and performing the procedure. The present study reviewed 264 tissues of 110 cases of frozen section biopsy, to assess the indication, accuracy and discrepancies in morphological examination to diagnose normal, nonneoplastic and neoplastic lesions. When FS were compared with paraffin sections, seven cases were discordant that included three cases of false negative(1.1%) and four cases of false positive (1.5%) diagnosis on frozen section. Key Words: Frozen section, Histopathology, Intraoperative consultation. *Address for Correspondence: Dr. Meena Rajiv Daveshwar, 18, Yantrika Society, Near Chanakyapuri, New Sama Road, Vadodara, Gujarat. 390024. Email: [email protected] Received Date: 20/10/2019 Revised Date: 17/11/2019 Accepted Date: 12/12/2019 DOI: https://doi.org/10.26611/1051239 confirmation of presence of representative samples for Access this article online paraffin section diagnosis and to determine further surgical treatment protocols.5,6 Quick Response Code: Website: www.medpulse.in MATERIALS AND METHODS It was a prospective analysis of 264 tissues of 110 cases of frozen section procedure. The gross specimens were Accessed Date: cut into thin slices and examined. Sections were taken from abnormal, suspected areas, or from firm lesions and 17 December 2019 placed in a mounting medium. The tissue was frozen immediately to -20 degrees centigrade inside the cryostat. After 10 minutes, when tissue was frozen, the chunk was INTRODUCTION inserted into clamping lever and was fixed. The Frozen Frozen section (FS) technique was first introduced by the sections were cut on a Leica cryostat machine at a William H. Welch, from John Hopkins Hospital in 1891. thickness of 5-7 micron and evaluated in Hematoxylin By the early and mid-1920s, the technique became and Eosin (HandE) stain. The sections were examined by popular and was used for intraoperative consultation consensus of minimum three pathologists, in correlation practice. The preparation of frozen section was made with appropriate clinical details. It was immediately easier in the 1950s and 1960s by the development of the conveyed to the operating surgeon. The turn around time modern cryostat, a cabinet cooled to -20 to -30 degree of entire specimen from receipt of specimen to delivery of Celsius and enclosing a microtome blade.1, 2, 3, 4. The main report was recorded. Subsequently, for the permanent purpose of frozen section is to provide rapid diagnosis to section, specimens were fixed in 10% neutral buffered guide intra or perioperative patient management. The formalin, grossed and adequate representative sections indications of frozen section are identification of tissue were taken according to the standard guidelines.5 and unknown pathological processes, evaluation of Conventional histoprocessing was performed in Yorco margins, identification of lymph node metastasis, automated tissue processor. The sections were then How to cite this article: Hiral Samir Shah, Meena Rajiv Daveshwar, Neema Ankur Rana. Correlation of intraoperative frozen section report and histopathological diagnosis. MedPulse International Journal of Pathology. December 2019; 12(3): 161-165. https://www.medpulse.in/Pathology/ MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 3, December 2019 pp 161-165 evaluated in HandE stain. The frozen section diagnosis conventional histopathology diagnosis in terms of were correlated with the final histological diagnosis to different histopathological categories, diagnostic accuracy assess the accuracy of the technique. The number and ,false positive and false negative cases including reasons type of discordance were compared and the discrepancies for limitations. Frozen section and histopathological were analyzed. Frozen section and routine histopathology diagnosis was concordant in 257/264 tissues, so diagnosis were compared to assess the diagnostic diagnostic accuracy of frozen section was 97.3%. Seven accuracy. The test results were categorized into cases were discordant with three cases reported as false concordant and discordant groups, the latter was negative (1.1%) and four cases as false positive (1.5%) on subdivided into false positive and false negative. frozen section (Table 1). Out of 264 tissues, maximum Indications, turnaround time and limitations of frozen number of tissues that is 176 were pathologically sectioning were also observed. unremarkable. Rest of the tissues showed inflammatory change in 10 tissues while benign, borderline and OBSERVATIONS AND RESULTS malignant histology in 39, 1 and 37 tissues respectively. Frozen section(FS) was performed on 264 tissues from 110 cases, and its diagnosis was compared with final Table 1: comparative analysis according to organ, morphological findings on histopathology and diagnostic accuracy Concor Discor Unable to S. N. No. of No. of Final HP Diagnosis Tissue processed dant dant process cases tissue N Infl Benign Borderline Malignant 1. Margins for evaluation 39 178 167 00 00 00 11 177 01 00 2. Ovary 23 24 01 00 18 00 05 22 02 00 3. Thyroid 10 12 00 01 06 00 05 12 00 00 4. Abdomen and pelvis 09 11 04 00 04 00 03 10 01 00 5. Breast 08 10 02 01 03 01 03 09 01 00 6. Head and neck 07 07 0 01 00 00 06 06 01 00 7. Periampullary region 04 06 01 01 01 00 02 06 00 01 8. Uterus, cervix, adnexal tissue 04 04 01 00 03 00 00 04 00 00 9. CNS 03 05 00 01 03 00 01 04 01 00 10. Lymph node 02 06 00 05 00 00 01 06 00 00 11. Paraaortic mmass 01 01 00 00 01 00 00 01 00 00 Total 110 264 176 10 39 01 37 257 07 01 Table 2: Comparison of false positive cases reported on frozen section Organ FS diagnosis HP diagnosis Reason Spindle cells with few epithelial like Pelvic mass Leomyoma Artefact cells suspected for malignancy Multiple hyperplastic and Ovarian tumor Borderline serous tumor Strauma ovarii papillary areas of thyroid gland (figure 1,2,3,4) misinterpreted as serous tumor Benign stromal tumor- Fibroma Artifact due to myxoid Ovarian mass Mucinous cyst with mural nodule Thecoma with myxoid degeneration degeneration Transeverse colon and liver Spindle cell sarcoma mostly Epithelial malignancy Very small biopsy nodule leomyosarcoma Table 3: Comparison of false negative cases reported on frozen section Organ FS diagnosis HP diagnosis Reason Squamous papilloma with high grade Squamous cell carcinoma arising Sampling error; deeper section of Nasal cavity mass dysplasia(carcinoma in situ) from squamous papilloma paraffin tissue showed area of invasion Out of five margins, lateral margin is Lateral margin showed involvement Infraorbital mass Sampling error free by tumor cells Stroma of both the lesions are benign looking. So overlapping Inflammatory lesion over nasal Nasal cavity mass Glomangiopericytoma histopathological features can lead to papilloma misinterpretion. In addition glomangiopericytoma is very rare lesion. MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 12, Issue 3, December 2019 Page 162 Hiral Samir Shah, Meena Rajiv Daveshwar, Neema Ankur Rana Table 4: Frozen section diagnosis analysis in 264 tissues Frozen section diagnosis in 264 tissues Accuracy (%) 257/264(97.3%) Discordance rate(%) 7/264 (2.7%) False positive (%) 4/264(1.5%) False negative (%) 3/264(1.1%) Unable to process 1/264(0.38%) The primary indication for FS was evaluation of margins for presence of tumor in 39 cases (178 tissues). Out of 178 margins, one margin showed presence of tumor in deeper paraffin section. The second commonest tissue received was 23 cases of ovarian mass (24 tissues), for presence/typing of neoplasm. Out of 24 tissues of the ovarian tumor FS diagnosis showed discordance with paraffin section in two cases which were diagnosed false positive.( Table 2) The overall accuracy was 97.3% with false positive rate of 1.5%, false negative rate of 1.1%. The discordance rate was 2.7%. One case (0.38 % ) was not possible for histoprocessing as biopsy bit was very small. The false positive diagnosis were due to interpretation error and the unavoidable freezing artifact (Table 2) while sampling error was the main reason for the false negative diagnosis. (Table 3) Figure 1 Figure 2 Figure 3 Figure 4 Figure 1: pelvic mass showing extensive degenerative changes diagnosed as leiomyoma on histopathology examination; Figure 2: FS slide showing papillary like areas with numerous cysts diagnosed as struma ovarii on histopathology examination; Figure 3: squash preparation showing finger like projections with few benign thyroid follicular cells on right side diagnosed as struma ovarii in histopathology examination; Figure 4: Diffuse and fascicular proliferation of epithelioid hyperchromatic cells diagnosed as epithelioid leiomyosarcoma on histopathology examination DISCUSSION showed the rate of complete excision increased after the Frozen section is a multistep process involving surgical introduction of frozen section examination, reaching 89% resection, intraoperative preparation of slides and their by Mak AS 14. We had single case of discordance in microscopic examination, communicating FS diagnosis to evaluation of margin of squamous cell carcinoma may be surgeon and processing the remaining tissue for further due to improper orientation of specimen. The cutting workup. Errors may occur due to problems in any of the artifact also plays a crucial role for misinterpretation of steps 11. Quality of prepared sections during cryostat frozen section diagnosis which is enhanced by sectioning plays an important role in FS diagnosis.
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