Frozen Section Biopsy

Ma. Minda Luz Meneses-Manuguid, M.D.

Frozen section biopsy
‡ Biopsies are small samples of tissue taken from a mass or tumor that are examined under a microscope to make a diagnosis. ‡ Biopsies are used most often to determine whether cancer cells are present, although certain infections and other diseases can be diagnosed as well. ‡ A specific type of biopsy procedure called the frozen section was developed in order to make a rapid diagnosis of a mass during surgery. ‡ The frozen section is a laboratory procedure to perform rapid microscopic analysis of a specimen. It is used most often in oncological surgery. The technical name for this procedure is cryosection.

Frozen Section Procedure
‡ The surgeon removes a portion of the tissue mass. This biopsy is then given to a pathologist. ‡ The pathologist freezes the tissue in a cryostat machine, cuts it with a microtome, and then stains it with various dyes so that it can be examined under the microscope. The procedure usually takes only minutes. ‡ The quality of the slides produced by frozen section is of lower quality than formalin-fixed, wax-embedded tissue processing. While diagnosis can be rendered in many cases, fixed tissue processing is preferred in many conditions for more accurate diagnosis.

Technical aspects
‡ The key instrument for cryosection is the cryostat, which is essentially a microtome inside a freezer. ‡ The microtome is a very accurate "deli" slicer, capable of slicing sections as thin as 1 micrometer. The usual histology slide is cut at 5 to 10 micrometers. ‡ The surgical specimen is placed on a metal hold and frozen rapidly to about ñ20 to -30 °C. At this temperature, most tissues become rock-hard. Usually, colder temperature is required for fat or lipid-rich tissue, and cooler temperature for skin. Each tissue has a preferred temperature for processing. ‡ The specimen is embedded in a gel-like media known as Optimum Cutting Temperature (OCT) compound.

Technical aspects
‡ tissue must be sufficiently cold & hard to prevent compression & displacement of cell & tissue structures as the knife passes through. (if not cold enough, tissue melts & becomes adherent to the knife; if too cold, tissue becomes brittle, its resistance to cutting is increased, & it fragments upon cutting) ‡ the knife must also be chilled & maintained at low temp.The cutting blade must be sharp and set at the correct angle.

Cutting temperatures
‡ Recommended Temperatures for Cutting Unfixed Frozen Tissues ‡ Tissue Type Working Temperature Brain -12 ºC Liver, Lymph node -14 ºC Kidney, Spleen -16 ºC Muscle, Thyroid -20 ºC Skin, Breast -25 ºC Breast with Fat, Adipose tissue -30 ºC or below Fixed Tissue -12 ºC to -17 ºC

Technical aspects
‡ Subsequently the frozen tissue is cut with the microtome portion of the cryostat, the section is picked up on a glass slide and stained (usually with H & E) ‡ The preparation of the sample is much more rapid than with traditional histology technique (around 10 minutes vs 16 hours). However, the technical quality of the sections is much lower.

‡ The intraoperative consultation is the name given to the whole intervention by the pathologist: frozen section, gross evaluation, examination of cytology preparations taken on the specimen (e.g. touch imprints), and aliquoting of the specimen for special studies (e.g. molecular pathology techniques, flow cytometry). ‡ The report given by the pathologist is usually limited to a "benign" or "malignant" diagnosis, and communicated to the surgeon ASAP. ‡ The principal use of the frozen section procedure is the examination of tissue while surgery is taking place.

Indications for Frozen Section biopsy
‡ Mohs surgery - a simple method for 100% margincontrol of a surgical specimen. ‡ a sample of the suspected metastasis is sent for cryosection. This will help the surgeon decide whether there is any point in continuing the operation. Usually, aggressive surgery is performed only if there is a chance to cure the patient. If the tumor has metastasized, surgery is usually not curative, and the surgeon will choose a more conservative surgery, or no resection at all. ‡ Evaluation if surgical margin is free of tumor, an intraoperative consultation is requested to assess the need to make a further resection for clear margins.

Indications
‡ In a sentinel node procedure: a sentinel node containing tumor cells prompts a further lymph node dissection, while a benign node will avoid such a procedure. ‡ If surgery is explorative, rapid examination of a lesion might help identify the possible cause of a patient's symptoms. ‡ It is important to note, however, that the pathologist is very limited by the poor technical quality of the frozen sections. A final diagnosis is rarely offered intraoperatively. ‡ Rarely, cryosections are used to detect the presence of substances lost in the traditional histology technique, for example lipids. They can also be used to detect some antigens masked by formalin.

Advantages of Frozen section biopsy
‡ If more tissue is needed to make an accurate diagnosis, the surgeon is able to obtain an additional sample, avoiding a second operation. ‡ ‡ If the tissue is determined to be cancerous and is amenable to surgery, the mass can be removed at that time. ‡ ‡ If the tissue is determined to be benign (not cancerous), then the mass may not always need to be removed and the surgery can end. ‡ ‡ The frozen section biopsy can help ensure that the mass being removed is the intended tissue for removal. ‡ ‡ It can help ensure that the entire mass and its surrounding borders are removed. ‡ ‡ It allows for the collection of proper tissue samples for further scientific research. ‡ ‡ The surgeon and pathologist are able to collaborate to care for the patient.

Frozen section biopsy
Sometimes pathologists are not able to determine the diagnosis based on the frozen section and instead must rely on the permanent section. Although this takes longer than a frozen section (usually 1 day), the permanent section leads to better-quality microscope slides. All biopsies are limited by the sample taken. Cancer or other diseases may be so small that they are not present in the tissue sample but may still be present elsewhere. Multiple biopsies may be needed to make a diagnosis

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