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Frozen Section Procedure

Surgeon removes portion of tissue
mass

Specimen sent to the pathologist

Specimen frozen with a cryostat

machine

Cut using a microtome

Staining
Importance of Frozen Section of Ovarian
Masses
• Preoperative assessment rarely provides a study confirming
malignancy (25%)
• Guidance of surgical management
• Radical vs. conservative therapy
• Fertility, hormonal consequences
What to Know Before Frozen Section
• Availability of cryostat machine
• Request form should have been received well in advance
• What does the surgeon want to know?
• What is the patient’s clinical history?
• What specimen has the surgeon sent?
• Surgeon’s contact details
Indications for Frozen Section
• Provide an accurate and prompt tissue evaluation
• Assessment of primary site, histological subtype, and grade of tumor
• Assess margins when additional excision to obtain negative margins is
an option
• Determine extent of local tumor invasion and distant metastases
What to Know During Frozen Section
• Tissue sample should be adequate
• Interface between normal and abnormal tissue should be <2–3mm
• Type of tissue should be cut at the appropriate temperature
• Turnaround time
• 15 minutes – slides prepared
• 20 minutes – communicate results
 General Considerations in Intraoperative
General Considerations – Patient Factors
Evaluation
• Age • Gross Examination
• Premenarchal vs Postmenopausal • Specimen intact?
• Menopausal status • Surface excrescences?
• Bilaterality
• Frozen section examination
• Sample grossly concerning areas
• Differentiate primary from metastatic malignancies

Clinical Case
• 42-year-old female with a left ovarian mass measuring 5.3 cm
• G1P1 (1-0-0-1)
• No history of OCP use
• Familial history (+) breast cancer (mother)
• Undergoing laparoscopic salpingo-oophorectomy and potential
staging/debulking
Gross Specimen Gross Specimen

Low Power
High Power Magnification
Magnification
High Power Magnification High Power Magnification

Immuno-histochemical Stains Differential Diagnoses

HIGH GRADE SEROUS OVARIAN SEROUS LOW GRADE SEROUS
CARCINOMA BORDERLINE TUMOR CARCINOMA

Nonhierarchical
✓ ☓ ✓
branching

Uniform cellular
☓ ☓ ✓
population

Mild to moderate atypia ☓ ✓ ✓

(+) fibrous stroma ☓ ✓ ✓

~↓ mitotic activity ☓ minimal ✓

DDx – High Grade Serous Carcinoma DDx
Nonhierarchical branching
Micropapillary architecture FOCAL SBT with Focal Micropapillary
Architecture
Cribriforming

Nonhierarchical branching
Micropapillary architecture DIFFUSE Non-invasive MPSC
Cribriforming

Destructive invasion Low Grade Serous Ovarian CA

LGSOC Overview
• Most common malignant ovarian tumor (~40%)
Diagnosis: • Occur later in life
• May occur earlier in familial cases
Low Grade Serous Ovarian
Carcinoma (LGSOC)
Pathogenesis Clinical Manifestations
Adenofibroma/Cystadenoma

• Behaviour depends on the degree of differentiation and the

Atypical Proliferative Serous Tumor
distribution
• S/Sx include:

SLOW & STEPWISE

• Abdominal bloating
GENE MUTATIONS Non-invasive Micropapillary Serous CA • Difficulty eating/early satiety
• KRAS
• BRAF • Weight loss
• ERBB2 • Pelvic area discomfort
• Wild type TP53 Invasive Micropapillary Serous CA • Changes in bowel habits
• Urinary symptoms

LOW GRADE SEROUS OVARIAN CARCINOMA

Treatment of LGSOCs Prognosis

• First-line therapy: Primary cytoreductive surgery • LGSOCs progress very slowly; patients may survive for relatively long
• Take into account patient’s desire for fertility periods of time
• Bilateral/unilateral salpingo-oophorectomy with para-aortic lymph node • 5 year survival rate
dissection
• Without peritoneal metastasis – 70%
• Systemic chemotherapy – use is still debated • With peritoneal metastasis – 25%
References
• Coffey, D. M., & Ramzy, I. (2012). Frozen section library: Gynecologic pathology
intraoperative consultation. New York, NY, NY: Springer.
• HUI, P. B. (2016). Atlas of intraoperative frozen section diagnosis in gynecologic
pathology. Place of publication not identified: SPRINGER INTERNATIONAL PU.
• Ricciardi, E., Baert, T., Ataseven, B., Heitz, F., Prader, S., Bommert, M., Schneider, S.,
du Bois, A., & Harter, P. (2018). Low-grade Serous Ovarian Carcinoma. Geburtshilfe
und Frauenheilkunde, 78(10), 972–976. https://doi.org/10.1055/a-0717-5411
• Taxy, J. B., Husain, A. N., & Montag, A. G. (2014). Biopsy interpretation: The frozen
section. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
• Vang, R., Shih, I., & Kurman, R. J. (2009). Ovarian low-grade and high-grade serous
carcinoma: pathogenesis, clinicopathologic and molecular biologic features, and
diagnostic problems. Advances in anatomic pathology, 16(5), 267–282.
https://doi.org/10.1097/PAP.0b013e3181b4fffa