Laboratory of Pathology - Staff

FROZEN SECTION PROCEDURE AND POLICY

The following are established guidelines that must be observed by all Surgical Pathology Residents and Staff for the handling of frozen sections:

1.  Frozen sections will be done and read by the attending on service for the week and the resident covering autopsy
   service.  An exception occurs with neurologic frozens that are read by the neuropathologist.
2.  Frozen section controls will be submitted and processed as rushes and the slides reviewed by the “hot seat” resident and the attending on service.
   
   If a discrepancy is identified between the actual frozen section and the control section, the attending identifying the differences should:
   
   

• • Immediately contact the attending who read the initial frozen section and review the material with him/her.
  • If no agreement is reached, the case should be brought to the attention of the Head of the section.
  • If there is agreement between the attendings, the attending who read the original frozen section is responsible for contacting the surgeon/clinician responsible for the case, and to notify him/her of the error.  This is a courtesy to the pathologist, and it will also allow for adequate and prompt clinical decisions.
  • Documentation of the discrepancy should be incorporated as a “note” in the final surgical pathology report.  The report should also indicate that both pathologists (reading and reviewer) have reviewed the case and concur.  The note should document that the clinician was notified.
  • The result of the review of the frozen section and its controls (agreement or discrepancies) is flagged in SoftPath after the case is signed out.
  • Frozen section (intraoperative consult) discrepancies are reviewed as a part of the laboratory’s Quality Management Program.
  3.   All discrepancies should be brought to the attention of the section head, who along with the QM Chairman, will
        decide if further action is necessary.
• 4.   On-call team (composed of the Surgical Pathologist on-call and the resident on-call, Neuropath frozens are typically
        read by the Neuropathologist) will perform frozen section at night and on weekends.

Frozen sections have priority over other functions and must be handled immediately upon receipt.

The resident or attending will review the gross specimen and select the area to be frozen.  Glass slides to be used should be labeled with the patient’s last name, the date and the frozen section number prior to use.  Unlabeled frozen section slides must not be stained or leave the frozen room.

Tissue blocks may be frozen by immersion in freezing medium or by placement on the freezing arm within the cryostat.  The tissue will be cut and stained by the resident, pathologist, or PA.  The resident will review the case and arrive at a diagnosis.  This will be reviewed with the attending on service.  The information will then be conveyed to the surgeon by the resident or attending.

While speed is paramount in handling frozen sections, thought should not be dismissed.  When a frozen section request is received, be certain you understand the question that is asked.  If this is not clear, call the surgeon over the intercom.  Ask yourself whether you think a frozen section is contraindicated, if so, consult your attending.  In general, quickly analyze the request and then keep the process moving without delay.  The average time for a frozen section (from time of receipt in surgical pathology to the verbal report to the surgeon) should be 20 minutes.  At the time of frozen section, you should also decide whether special procedures may need to be performed for definitive diagnosis.  This decision should be made soon after the tissue is received because cell ultrastructure deteriorates within minutes –especially upon dehydration with air or alcohol –and antigens, especially small peptides, “diffuse” rapidly from the cell of origin.  As a general rule, tissue should be prepared for IHC and molecular studies of:

• All tumors of uncertain cytogenesis
• All lymph nodes submitted for primary diagnosis (consult the HemePath fellow on rotation)

REMEMBER:

THE SMALL AMOUNT OF TIME TO PREPARE TISSUE APPROPRIATELY IS INCONSEQUENTIAL COMPARED TO THE INABILITY TO POSSIBLY MAKE A PRECISE DIAGNOSIS BECAUSE TISSUE WAS NOT APPROPRIATELY HANDLED.

GENERAL PATHOLOGY AND SUMMARY

The pathologist should always be conservative with frozen section, but accurate.  A diagnosis of invasive breast carcinoma should be, in fact, invasive breast carcinoma with no hesitation if that is what the slide shows.  Too many surgeons and too many pathologists imply an uncertainty in all frozen sections and take the philosophy of waiting for permanents.  If the frozen section is definite, and many are, a definite diagnosis should be made.