Frozen Section Diagnosis,

Indications and Pitfalls

• Bone (Cases 1-10)

• Gynecologic (Cases 11-15)

• Anthony Montag, M.D.

 Frozen Section Diagnosis:
Indications and Pitfalls USCAP 24

• Anthony Montag MD Bone and Gyn

• Jerome Taxy MD Breast and GU
• Aliya Husain MD Peds and Pulm
 Frozen sections, a brief history
• 1891 William Henry
Welch produced the
first frozen section for
William Halstead
– Halstead had left the
OR prior to receiving
the report
• 1895 Cullen reports a
15 minute technique
from Welch’s lab
• 1905 Louis B
Wilson of Mayo
clinic develops
rapid frozen section
method using
methylene blue
• Credited with
establishing FS as a
practical technique
• Joseph Colt Bloodgood
– Surgeon at Hopkins
• “Since 1915, and certainly
since 1922, the public has
become so enlightened that
malignant disease…can be
properly discovered only by
an immediate frozen
section” 1927
• “There is a greater demand
today for pathologists…than
for operators” 1935
 Indications for Frozen Section

• To make an intraoperative decision

concerning further surgery
• Margins
• To assess adequacy of specimen when an
open biopsy is being performed
• To plan work-up and special studies on the
specimen
 Quality assurance indicators in
Frozen Section: Turn around time
• 90% of all frozen sections ready within 15 minutes
of receipt
• 90% of all diagnoses reported within 20 minutes
of receipt
• Longer times occurred when multiple pathology
opinions, residents involved, retrieval of previous
material, technical problems, or eventual deferral
Arch Pathol Lab Med 1997; 121 (6): 559-67
 Frozen section discrepancy rates
Journal Year % Discrep Sampling Diagnostic
Arch Path Lab Med 1990 3.5% 43% 43%
Arch Path Lab Med 1991 1.7% 57.5% 40%
Mayo Clinic Proc 1995 2.2% 73% 23%
Arch Path Lab Med 1996 1.42 61.4% 31.8%

–Acceptable rate for diagnostic error is 1%

Deferral rate for frozen section

Journal Year Deferral %

Arch Path Lab Med 1991 4.2%

Mayo Clinic Proc 1995 2%
Arch Path Lab Med 1996 4.6%
The more experienced the laboratory, the lower
the deferral rate.
Mayo is different.
4% is considered acceptable deferral rate
General rules before interpreting
bone lesions, in biopsy or frozens
• Must have history
– Age, multifocality, bone involved, location,
– Symptoms, duration, history of fracture
– History of previous malignancy or infection
• Must see radiograph, or have the
radiologist’s differential diagnosis
• Surgeon’s clinical differential diagnosis
• Know the Surgeon’s Algorithm
 Surgeon’s algorithm, after limb
salvage
Frozen section

malignant benign
await staging curettage
and chemo

malignant benign benign malignant

limb salvage second surgery amputation
for curettage Oops!
 Case 1
• Eighteen year old male who presented with
complaint of knee pain for 6 weeks
following badminton injury.
 Case 1: Chondroblastoma
• Age, radiologic
appearance point to
differential of
epiphyseal lesion
– Chondroblastoma
– Giant cell tumor
– Clear cell
chondrosarcoma
Chondroblastoma Giant cell tumor
Clear cell
chondrosarcoma
 Giant cell tumor vs Chondroblastoma vs
Clear cell chondrosarcoma
GCT CHBL CLCHS

Age 20’s to 30’s Teens to Most 30’s to

20’s 50’s
Giant cells +++ ++ +

Osteoid Reactive + Calcified Bone

“osteoid- spicules
like” matrix
Cell type Spindle Polygonal “Swollen”
 Case 2
• 12 year old boy with slowly enlarging lower
leg mass and developing foot drop.
 Case 3
• 12 year old male with R knee pain for
several months.
 T2
4-14-03
 ABC (case 2) vs Telangiectatic
Osteosarcoma (Case 3)
• Similar radiology
• Same age
• Same cystic appearance
• Stromal pleomorphism
• Atypical mitoses
• Fine meshwork of osteoid
• Tumor necrosis
 Case 4
• 12 year old boy with painful swelling in
hand of several weeks duration. No history
of trauma.
North American Blastomycosis
 Case 5
• 18 month old male has not been using his
left arm for one week. He has not had fever
or any other systemic problem. On physical
exam, the left forearm and elbow are
diffusely tender to palpation. There is no
erythema or increased warmth. There is no
palpable mass. Laboratory values are as
follows: WBC-11.9 (21.5 at the outside
hospital), ESR57, and CRP-2.3.
Langerhans cell
histiocytosis
 “Marrow cell process” lesions
• Chronic osteomyelitis
• Histiocytosis X
• Ewing’s sarcoma
• Lymphoma
• Metastasis
 Case 6
• 45 y/o M with ~ 6 month history of right
proximal thigh pain without history of
trauma. Patient denies other medical
problems and has otherwise felt fine.
1/17/02
2/18/02
2/20/02
Metastatic carcinoma
 Marrow process lesions, clinical points
• Identification of Small blue cell tumor/lymphoma
vs inflammatory/EG
– For directing work-up
• Identification of primary bone tumor vs met
– Primary bone malignancy gets therapy and limb salvage
– Metastatic disease gets internal fixation for stability
– Rodding of a primary bone tumor usually contaminates
the surrounding compartment adjacent joint, loosing
chance for limb salvage.
 Case 7
• 16 year old female presents with four
months of right groin pain.
Osteosarcoma
 Case 8
• 57 year old male with pain in the right
shoulder of long-standing duration. He
presented with an x-ray showing a lucent
lesion in the proximal humerus.
Subsequently, he suffered a pathologic
fracture through the lesion. Staging showed
no other primary tumors.
Gad- IV & IntraArtic.
Fracture callus
 Maturation stages of fractures

Days after fracture Histologic feature

< 3 days Hemorrhage, edema, tissue necrosis
3 to 7 days Reactive myofibroblasts, tissue culture
appearance
7 to 10 days Increasing cellularity and early osteoid
> 10 days Osteoid and cartilage matrix
2 to 3 weeks Osteoid rimming, broad seams of
osteoid
Clues that it is a fracture and not a tumor
• History
• Zonal appearance as seen in myositis ossificans
– Uniformly atypical cells in the same zone
• Single layer of osteoblast rimming
• Intermixture with chondroid matrix
• Prominent vascularity between spicules of woven
bone
• Decreased cellularity between spicules of woven
bone
• Organization of trabeculae of woven bone into
arches
Clues that it is osteosarcoma and
not fracture
• Radiograph with pre-existing Codman’s
triangle or soft tissue mass
• Infiltrative growth pattern
• Sheet-like arrangement, no to few well
formed spicules of woven bone, no rimming
• Atypia/pleomorphism and atypical mitoses
 Case 9

• 29-year-old man complains of

rapid onset of right groin and
thigh pain over the preceding 6
weeks. He does not report pain
at night or rest.
Low grade central
osteosarcoma
 Low grade central Fibrous dysplasia
osteosarcoma
Symptom Pain Deformity
Radiograph May destroy cortex, Better circumscribed
Coarsely trabeculated,
Stroma Low cellularity, may Low cellularity
coalesce around spicules
Osteoid Mixed woven and Woven only, short
lamellar, long trabeculae trabeculae
Atypia Subtle Absent
 Case 10
• The patient is a 32 year-old woman with
recent onset of pain in the right distal thigh.
Enchondroma
 Enchondroma vs chondrosarcoma
• Symptomatic, think chondrosarcoma
• Hands and feet, think enchondroma
• Less than 6 cm, think enchondroma
• Ossification of cartilage matrix at the edge
of lobules, think enchondroma
• Infiltrative pattern, think chondrosarcoma
• Greater than 1 mitoses on frozen slide, think
chondrosarcoma
 General rules for bone frozens
• Know history and radiology
• Know algorithm
• Woven bone is always abnormal
• Fracture can mimic a number of tumors
• Well formed zonal patterns are usually benign
• Osteoblast rimming is almost always benign
• Infiltrative growth and trapping of native bone is
malignant
– Except osteomyelitis with fibrosis
 General rules for bone frozens
• Well defined edge is benign
• Cartilage tumors of the hands and feet are benign
• Necrosis of cartilage is malignant
• Myxoid liquefaction of cartilage suggests
malignant
• Necrosis in a cystic lesion is probably malignant
• Any time the radiograph and the histology
disagree, defer
• Any time the clinical differential and the histology
disagree, defer
 Case 11
• 30 Year old woman presenting with recent
onset of acute abdomen. Physical exam
reveals a 10 cm mass.
• Grossly a 10x8x4 cm ovary with ruptured
capsule
Granulosa cell tumor
 Case 12
• 72 year old woman with ovarian mass
undergoes exploratory laparotomy
Undifferentiated
ovarian carcinoma
 Granulosa cell tumor vs undifferentiated carcinoma

• 45-55 year old peak • 55-60 year old peak

• 90% stage I • 90% stage III or greater
• 5% bilateral • 50% bilateral
• Usually no necrosis • Frequent necrosis
• Pleomorphic, large
• Uniform nucleoli
nuclei, scant cytoplasm
• Occasional, rarely • Frequent, sometimes
atypical atypical
• Oophorectomy • Staging
 Case 13
• 29 year old G3 P2 presenting for Cesarian
Section. An incidental 8 cm ruptured
ovarian mass was discovered during the
procedure.
Luteoma of pregnancy
 Ovarian lesions in pregnancy
• Majority are benign teratomas,
cystadenomas, or functional lesions
• Malignant lesions include
– Germ cell tumors 30-45%
– Borderline tumors 30-35%
– Cystadenocarcinomas 5 to 10%
– Sex cord stromal tumor 10 to 20%
 Luteoma Steroid cell Granulosa
tumor cell tumor
Age 20-30 40-50 20-70

Race 80% African No tendency No tendency

American
Laterality Multifocal or Unilateral Unilateral
bilateral
Histology Uniform Pink and Solid, cords,
pink cells in clear, lipid trabeculae
sheets vacuoles
Cytology Uniform Variable, Grooves
nuclei, like small nuclei
corpus
luteum
 Case 14
• 48 year old woman, G 0. With history of
perimenopausal bleeding and an
endometrial biopsy which was diagnosed as
having Grade I to II endometrial
adenocarcinoma.
• A 120 gram uterus with attached adnexa is
sent for intraoperative consultation.
Endometrial
adenocarcinoma, grade
3, stage at least IIB
 Intraoperative evaluation of
hysterectomy specimens in cases of
endometrial carcinoma

• Document histologic type, grade, extent of

myometrial penetration or endocervical
canal involvement to make the decision to
do a pelvic and periaortic lymph node
dissection
• Unnecessary if bad prognostic features were
present in a previous biopsy
Feature Relative increased risk of
lymph node metastasis
Serous or clear cell histology 3x

Grade 3 histology 3X

Outer half myometrial 5x

involvement
Cervical involvement 4x

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

• 6-8 micron sections

• Over-stain in Hematoxylin by 30 secs.
• Clarify site and purpose of frozen (pathologist’s
responsibility)
• FS not recommended for primary diagnosis
 Medicolegal case
1. DISTAL COLON: Muscular wall with
ganglion cells present
2. PROXIMAL COLON: Colonic mucosa
and muscular wall. No ganglion cells
identified
3. PROXIMAL COLON: Colonic mucosa
and muscular wall with ganglion cells
present
Pitfalls in identifying ganglion cells
16 yom with constipation and rectal incontinence
Muscle hyperplasia
Suspicious for ganglion cell
Defer to permanents
4 day old with bowel obstruction – meconium peritonitis
Necrotizing enterocolitis
1 m old with desc. colon obstruction – post-NEC stricture
Hirschsprung’s dis. – nerves in serosa
Premature ganglion cells
HD – pale staining Ganglion cells pale staining

Ganglion cells pale staining

 Case 3
• 7 year old male with large pelvic mass,
exploratory laparotomy done for open
biopsy.
Case 3 - Touch preparation
Case 3 - Touch preparation
Case 3 - Frozen section
Diagnosis: Favor lymphoma, other
small blue cell tumors to be ruled out
Purpose: Specimen triage
 Case 4
• 9 year old male with abdominal mass, who
on exploratory laparotomy was found to
have enlarged lymph nodes compressing the
cecum. First frozen was sent, labeled
“pericecal mass”.
Case 4 - Pericecal mass
Case 4 - Pericecal mass
Case 4 - Pericecal mass
Case 4 - Pericecal mass
Diagnosis: Edematous connective
tissue, fat and focal lymphocytic
infiltrate (reactive lymph nodes)
 Case 5
• 10 year old female with left posterior thigh
mass, which is biopsied and sent for frozen
section.
Case 5 - Thigh mass
Case 5 - Thigh mass
Diagnosis: Small blue
cell tumor
Final diagnosis: PNET
 Case 6
• 6 year old female with right renal mass.
Nephrectomy specimen (134 g) sent for
frozen. A 2.5 cm cystic lesion filled with
grey tan granular tissue admixed with
blood, which was readily separable from the
cystic wall, was sectioned.
Case 6 – kidney
Case 6 – Kidney tumor
Case 6 Kidney tumor
Case 6 – Kidney tumor
Diagnosis: Most consistent with
cystic nephroma
Case 6 – Kidney tumor
Final diagnosis: Papillary renal cell
carcinoma
 FS for Pediatric Renal Tumors
• Neither necessary nor indicated
• Only done if operation will change
• For unresectable tumor, assess adequacy of
biopsy specimen
• Histologic type, grade and stage difficult
enough on optimum permanent sections
• No need for contralateral biopsy/FS
 Case 7
• 7 year old male with history of
dermatofibrosarcoma protuberans on left
upper back, status post biopsy. Now
undergoes wide local excision which is sent
for frozen to evaluate the deep margin.
Case 7 – Dermal lesion
Case 7 - dermal lesion
Case 7 – Dermal lesion
Case 7 – Deep margin
Case 7 – Deep margin

Case 7 – Deep margin

Case 7 – Deep margin
Diagnosis: Suspicious for DFSP
Case 7 – Permanent section
Case 7 – Permanent section
Diagnosis: Margin free
 Case 8
• 7 year old male with left forearm nodule,
which is excised and sent for frozen. The
specimen consists of soft tissue with a firm
0.6 cm nodule.
Case 8 – Forearm nodule
Case 8 – Forearm nodule
Case 8 – Forearm nodule
Diagnosis: benign, R/O
granuloma annulare
 Case 9
• 5 year old female with cervical
lymphadenopathy.
Case 9 – Cervical lymph node
Case 9 – Cervical lymph node
Diagnosis: C/W Rosai-Dorfman disease
 Lung and Pleura
• Peripheral lung nodule
– Benign or malignant
– Small or non-small cell
– Primary or metastatic
– Resectable or not
• Mediastinal lymph nodes (+ or -)
• Pleura
– Benign or malignant
– Mesothelioma or metastatic
 Cases 10a & b

• Case 10a: 68 year old male with right lung

mass. Endobronchial biopsy (EBBx) sent
for frozen.
• Case 10b: 60 year old female with
mediastinal mass. Left main stem bronchus
EBBx sent for frozen.
 Case 10a – EBBx lung
Squamous cell carcinoma
(unresectable)

Case 10b – EBBx lung

Small cell carcinoma
(unresectable)
 Case 11
• 61 year old female with lung mass. Needle
biopsy sent for frozen.
Case 11 – Lung mass
Case 11 – Lung mass
Non-small cell carcinoma,
lobectomy done (all ln -)
 Case 12
• 73 year old male with left upper lobe
nodule. Wedge resection containing a
1.1 cm mass sent for frozen.
Case 12 – Lung nodule
Case 12 – Lung nodule
Case 12 – Lung nodule
Positive for malignancy
Case 12 – Lung nodule
Small cell carcinoma
Case 12 – Lung nodule
Differential diagnosis
 Case 13
• 72 year old male with lung nodule. Level 7
lymph node sent for frozen.
Case 13 – L7 lymph node
Metastatic carcinoma
 Case 14
• 64 year old female with right upper lobe
nodule and history of chronic lymphocytic
leukemia. A 1.5 cm wedge biopsy was
entirely submitted for frozen.
Case 14 – Lung nodule
FS Dx: Fibrosis
Case 14 – Lung nodule
Case 14 – Permanent section
Case 14 – Lung nodule
Case 14 – Lung nodule
Case 14 – Lung nodule
Adenocarcinoma
 Case 15
• 64 year old female with right lung nodules.
Wedge biopsy sent for frozen.
Case 15 – Lung nodules
Case 15 – Lung nodules
Organizing pneumonia
 Case 16
• 82 year old female with left lung nodule,
S/P treatment for head and neck carcinoma.
Wedge biopsy of lung containing a 0.9 cm
nodule is sent for frozen. Two blocks cut for
frozen (FS1a and FS1b).
Case 16 – FS1a Lung nodule
Case 16 – FS1a Lung nodule
Organizing pneumonia
Case 16 – FS1b Lung nodule
Case 16 – FS1b Lung nodule
PD carcinoma, probably squamous
 Case 17
• 80 year old male with spontaneous
pneumothorax who undergoes VATS
(video-assisted thoracoscopic surgery)
pleural biopsy.
Case 17 – Pleural biopsy
Case 17 – Pleural biopsy
Case 17 – Pleural biopsy
Case 17 – Pleural biopsy
Fibrosis, inflammation and
mesothelial hyperplasia
 Case 18
• 63 year old male with recurrent pleural
effusions undergoes thoracoscopic pleural
biopsy which is submitted for frozen
section.
Case 18 – Pleural biopsy
Case 18 – Pleural biopsy
R/O mesothelioma
Invasion into fat
Extensive tumor
Extensive tumor
Tumor necrosis
Mesothelioma versus hyperplasia
• Invasion into skeletal • Non-invasive (but
muscle or fat mesothelial cells are
• Large amount of present within fibrous
mesothelial cells in tissue)
sheets • Layering effect with
• Frank malignancy, fibrin and mesothelial
areas of necrotic tumor cells on one side, and
cells granulation tissue/
fibrosis on the other
 Case 19
• 67 year-old female with CML, in blast crisis
who presented with a nasal “polyp”.
Case 19 – Nasal polyp biopsy
Case 19 – Nasal polyp biopsy
Fungal hyphae present
 FROZEN SECTION
(USCAP SHORT COURSE #24)

BREAST
SENTINEL LYMPH NODE (BREAST)
KIDNEY
PROSTATE
URINARY BLADDER

Jerome B. Taxy, M.D.

University of Chicago
 CASE 1

A 65 year old woman had an infiltrating ductal carcinoma of the left

breast 3 years previously treated by lumpectomy at an outside hospital.
She was referred to the University of Chicago where a sentinel node
biopsy was positive for metastatic tumor. A full axillary dissection
yielded an additional 19 positive nodes out of a total of 31. She received
local radiation and chemotherapy.

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

TUMOR SIZE NUMBER BREAST AXILLA

<2.0 cm. 201 121 80
Survival (%) 74 88 54
2.0-2.9 cm. 396 185 211
Survival (%) 60 74 48
3.0-3.9 cm. 318 119 199
Survival (%) 48 69 35
4.0-4.9 183 65 118
Survival (%) 42 60 31
>5.0 cm. 257 57 200
Survival (%) 34 75 22
 CASE 2

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

• FIRST TO RECEIVE LYMPHATIC DRAINAGE FROM

ORGAN/TUMOR
• MOST LIKELY TO CONTAIN A METASTASIS
• SUITABLE REPLACEMENT FOR AXILLARY DISSECTION AS A
STAGING AND DIAGNOSTIC PROCEDURE FOR T1 AND T2
TUMORS
• CLINICAL ADVANTAGES
– Prevent pain, limitation of motion, lymphedema, infection
– Provides comparable information to standard axillary dissection
• PATHOLOGIC ADVANTAGE: More focused examination
• UNRESOLVED ISSUES
– Extent of examination
– What is a (clinically relevant) metastasis?
– What constitutes a negative lymph node?
 SENTINEL NODE FROZEN SECTION

ADASP RECOMMENDATIONS CLINICOPATHOLOGIC

ALGORITHM (U of C)

• Intraoperative evaluation is not • Frozen section

recommended unless there are to be – Prepare to complete the axillary
immediate management changes.
dissection irrespective of the size
of the metastasis
• Examine each node entirely:
– Some patients may be
– Cut at 3-4 mm intervals overtreated
– Levels
– Recognize the technical
limitations
• Specify how metastases are
identified. – Accept a low rate of false
negative interpretation
• No axillary dissection after a negative
sentinel node
 CASE 3

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

CYSTIC RENAL ADENOCARCINOMA, CLEAR CELL TYPE

MARGIN OF RESECTION NEGATIVE FOR TUMOR
 CASE 5

A 62 year old man with previous prostatic needle biopsies showing

bilateral adenocarcinoma, Gleason 6 (3+3) in less than 5% of cores from
each side. The PSA was 3.74 ng/ml. Six months previously, he had a right
partial nephrectomy for an oncocytoma with negative margins. He now
undergoes a robotic assisted laparoscopic radical prostatectomy. The
images are from the neurovascular bundle on the left side. The treatment
decision is whether to excise additional tissue from that location.
DIAGNOSIS CASE 5: PERIPHERAL MARGIN POSITIVE FOR
ADENOCARCINOMA
 NERVE SPARING RADICAL PROSTATECTOMY:
CONTRAINDICATIONS

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

• HISTORICAL – MOSTLY URETERAL

– UP TO 18% POSITIVE MARGINS
– HIGH STAGE AND GRADE TUMORS
– URETHRA?
• CURRENT BENEFIT QUESTIONABLE
– SURGERY ALONE NOT CURATIVE
– PATIENTS DIE OF DISSEMINATED DISEASE
– ANASTOMOTIC RECURRENCES, SEPARATE UPPER TRACT OR
URETHRAL TUMORS UNCOMMON
 CANDIDATES FOR UROTHELIAL FROZEN SECTION

• DIFFUSE CIS
• PROSTATIC DUCT INVOLVEMENT
• GROSS URETERAL INFILTRATION DISCOVERED AT SURGERY
• MOST FROZEN SECTION REQUESTS UNNECESSARY