Intraoperative examination of the sentinel lymph node for breast carcinoma staging.

Intraoperative pathologic examination of the sentinel lymph node (SLN) draining a primary breast carcinoma allows an SLN-positive patient to undergo complete axillary lymphadenectomy as part of the same surgical procedure. However, the optimal technique for rapid SLN assessment has not been determined. We reviewed our results with imprint cytology (IC) and frozen section (FS) examination of SLNs from 278 patients. Compared with H&E-stained paraffin sections, IC and FS had an overall accuracy of 93.2%. The false-reassurance rate (false-negative results/all negative results) was 8.4%. It correctly identified 98% of macrometastases but only 28% of micrometastases. There were no false-positive results. Compared with paraffin-section cytokeratin immunohistochemistry results, the IC-FS false-reassurance rate increased to 25.8%. The false-reassurance rate decreased with smaller primary tumor size (T1 vs T2/3) and ductal type, smaller diameter of the SLN (< or = 2.0 cm), and greater pathologist experience. IC combined with 2-level FS reliably identifies SLN macrometastases but commonly fails to detect SLN micrometastases. If SLN micrometastasis is used to determine the need for further lymphadenectomy, more sensitive intraoperative methods will be needed to avoid a second operation.     

Use of intraoperative stereomicroscopy for preventing loss of metastases during frozen sectioning of sentinel lymph nodes in breast cancer

Aims:  Optimal detection of metastases in sentinel lymph nodes (SLN) remains controversial. To determine the reliability of intraoperative frozen sections, SLN protocol with one frozen section was compared with macroscopic SLN evaluation with consecutive complete SLN embedding.
Methods and results:  SLN from 135 consecutive breast cancer patients were analysed under a sereomicroscope. Frozen sections were performed in suspicious or clearly involved SLN on cut surface. One control group ( n  = 143) underwent one intraoperative frozen section on each SLN. The second control group ( n  = 90) was subjected to stereomicroscopy and one intraoperative frozen section on each SLN. A conventional SLN protocol with cytokeratin immunohistochemistry was performed postoperatively in all cases. All groups were statistically comparable. In the study group metastases were suspected in 21 SLN (16%) under the stereomicroscope and all were confirmed histologically. The negative SLN rate was significantly lower in the study group than in the main control group (47% versus 64%, P  = 0.008), suggesting loss of metastases during frozen sections. More macrometastases were detected in the study group (30% versus 15%, P  = 0.006); there were no differences in isolated tumour cells or micrometastases. The false-negative rate was significantly lower in the control groups (29% versus 13% and 12%, P  = 0.001).
Conclusions:  Frozen sections potentially lead to loss or reduced size of metastatic deposits in SLN. Avoiding intraoperative frozen sections on grossly inconspicuous SLN may therefore be justified.     

Intraoperative sentinel lymph node evaluation in patients with node-positive breast cancer status post neoadjuvant systemic therapy - An institutional experience

Recent studies have shown the feasibility and utility of sentinel lymph node (SLN) biopsy in patients with biopsy proven node-positive breast cancer after neoadjuvant chemotherapy. We reviewed our experience in intraoperative SLN evaluation in such cases and its effect on axillary management. A retrospective analysis of breast cancer patients (2015–2018) with a biopsy-proven positive axillary lymph node, who received neoadjuvant systemic therapy and underwent intraoperative SLN assessment was performed. Intraoperative SLN assessment results were compared with final pathology. Its accuracy and effect on axillary management is summarized. We identified 106 patients with positive axillary lymph node and neoadjuvant systemic therapy between the ages of 28 and 75 years who had SLN biopsy and lumpectomy (33) or mastectomy (73). Three or more SLNs were identified in 91 cases (86 %). The previously biopsied lymph node was identified as one of the sentinel lymph nodes in 93 cases (88 %). There is a high concordance rate between frozen section diagnosis and final diagnosis on sentinel lymph nodes. No false positive case and seven false negative frozen section diagnosis cases (diagnosed as negative on frozen section and positive on permanent sections) were identified. False-negative frozen section diagnosis correlated with low-volume nodal disease and obscuring tumor bed changes. Almost half of the positive lymph nodes were converted to negative after neoadjuvant chemotherapy. SLN biopsy with intraoperative frozen section evaluation after neoadjuvant systemic therapy in node-positive patients is an effective way to minimize axillary surgery.     

Intraoperative evaluation of sentinel lymph nodes in breast carcinoma by imprint cytology,frozen section and rapid immunohistochemistry

Sentinel lymph nodes (SLN) isolated in 40 patients of breast carcinoma (stage T₁/T₂) were evaluated intraoperatively by imprint cytology and frozen section. Rapid immunohistochemistry (IHC) was done in cases where both imprint smears and frozen sections were negative for any metastatic tumor deposits. The results of these different techniques were compared with postoperative paraffin sections taken as “Gold Standard.” Nottingham modification of Bloom Richardson scoring system was used for grading the tumors. Further, the correlation of the SLN status with tumor size, grade, and lymphovascular invasion was studied. The sensitivity, specificity, and overall accuracy of imprint cytology were 91.7, 100, and 95% respectively, and those of the frozen section were 95.8, 100, and 97.5% respectively. Examination of multiple serial sections improved the sensitivity and overall accuracy of frozen section. Results of intraoperative rapid IHC were equivalent to final paraffin sections. Histological grade and lymphovascular invasion were in direct correlation with SLN metastasis (P < 0.05). The risk of lymphovascular invasion increased from 22.2% in grade I tumors to 85.7% in grade III tumors. SLN biopsy is a reliable method to evaluate the status of the axillary lymph nodes. Imprint cytology can be used reliably where the facility of frozen section is not available. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Metastases in axillary sentinel lymph nodes in breast cancer as detected by intensive histopathological work up

AIM: To assess the value of the intensive histological work up of axillary sentinel lymph nodes (SLN) to demonstrate regional metastatic disease. METHODS: From a series of 58 successful lymphatic mapping procedures, 78 SLN were analysed by serial sections (mean of 49 levels/SLN) and by immunostaining to cytokeratin and epithelial membrane antigen, and the results compared with those obtained by assessing the central cross section. RESULTS: The central cross section would have failed to detect metastases in eight of 26 lymph nodes (31%) in patients with breast cancer metastasising to the SLN only. This would have led to a false negative node status in six of 21 patients (29%). Two micrometastases were detected with the aid of immunostains. CONCLUSIONS: The results suggest the need to examine SLN at multiple levels and to use immunohistochemistry in negative cases. Serial sections are also useful in the case of micrometastases, as some of these may convert to macrometastases at deeper levels. Multiple level investigation of SLN and immunohistochemistry in the event of the negativity of standard stains would result in improved staging and an increase in the proportion of node positive disease detected.     

Reliability of intraoperative frozen section and imprint cytological investigation of sentinel lymph nodes in breast cancer

AIMS: The sentinel lymph node procedure enables selective targeting of the first draining lymph node, where the initial metastases will form. A negative sentinel node (SN) predicts the absence of tumour metastases in the other regional lymph nodes with high accuracy. This means that in the case of a negative SN, regional lymph node dissection is no longer necessary. Besides saving costs, this will prevent many side-effects of lymph node dissection. The aim of this study was to evaluate the reliability of intraoperative cytological and frozen section investigation of the SN to detect metastases. This would allow the axillary lymph node dissection to be performed in the same session as the SN procedure and the excision of the primary tumour in case of a positive SN. METHODS AND RESULTS: Seventy-four SNs were detected by gamma probe detection of nanocolloid and visual localization of Patent Blue accumulations in 54 women with stage T1-2N0M0 invasive breast cancer. The identified SN were immediately investigated by frozen section and imprint cytological investigation. Diagnoses were confirmed on the paraffin material, and in case of negative frozen section and paraffin haematoxylin and eosin sections, skip sections and immunohistochemistry were performed. Thirty-one SNs (42%) contained metastases, of which 27 were detected by the frozen section procedure (sensitivity 87%). There were no false positives (specificity 100%). The sensitivity of the imprints was 62% with a specificity of 100%. When evaluating the data per patient, for the frozen section procedure the sensitivity was 91% and the specificity 100%, and for the imprints, the sensitivity was 63% and the specificity 100%. There were no SNs in which the imprints showed metastases and the frozen section did not. CONCLUSIONS: Intraoperative frozen section analysis is a reliable procedure by which a high percentage of sentinel lymph node metastases can be detected in breast cancer patients without false positive results. This allows the surgeon to perform an immediate axillary lymph node dissection in case of positive SNs. In up to 10% of cases, the final paraffin sections will reveal micrometastases that were not detected by the frozen section, and in these patients axillary lymph node dissection will have to be performed in a second session. The imprint method is significantly less sensitive than the frozen section but may be used as an alternative when frozen section is not possible.     

Frozen section diagnosis of pancreatic lesions

BACKGROUND: The clinical and radiologic diagnosis of pancreatic cancer and the safety of pancreatic resections have improved. These improvements, together with the indication for resection in some cases of complicated chronic pancreatitis, have reduced the necessity for confirmed preoperative tissue diagnosis. We investigated the clinical use and accuracy of frozen section diagnosis for pancreatic lesions. DESIGN: We searched archival files for the years 1989-2000 for patients with pancreatic lesions who had received a diagnosis based on frozen section results. We compared the diagnosis of all frozen section slides with that of the permanent sections and reviewed the clinical follow-up notes. We evaluated histologic features useful in differentiating between malignant and benign pancreatic lesions. RESULTS: A total of 538 patients underwent surgical biopsy and/or resection for suspected pancreatic lesions. Frozen section was requested in 131 cases (284 frozen sections). Ninety cases had frozen section of the pancreatic lesions, 70 cases had frozen section of metastatic sites, and 29 cases had frozen section of surgical margins. Of the 90 cases in which frozen section of the pancreatic lesions was requested, malignancy was diagnosed in 44, a benign lesion was diagnosed in 37, and the diagnosis was atypical and deferred in 9. In total, 3 false-negative frozen sections and 1 false-positive frozen section were identified for respective rates of 1.2% and 0.3%. In all cases in which the frozen section diagnosis was deferred or was inconsistent with the operative impression, and the surgeon acted on his/her impression, the operative diagnoses were subsequently confirmed by additional permanent sections and/or clinical follow-up. The most useful histologic features for the diagnosis of pancreatic adenocarcinoma in frozen sections were variation in nuclear size of at least 4:1, disorganized duct distribution, incomplete duct lumen, and infiltrating single cells. CONCLUSIONS: Frozen sections are useful in conjunction with the impression at surgery for the management of patients with pancreatic lesions. Frozen sections of resection margins were 100% accurate; frozen sections of pancreatic lesions or metastatic sites were accurate in 98.3% of cases. We found an acceptable rate of deferred frozen section (6.6%). The experienced surgeon's impression of malignancy is reliable in cases in which frozen section is deferred or has negative findings.     

Accuracy and cost of intraoperative lymph node frozen sections at radical prostatectomy

AIM: To assess the value of intraoperative diagnostic examination of frozen sections of lymph nodes removed during radical prostatectomy. METHODS: Pelvic lymph nodes from patients with prostatic carcinoma were obtained (1) as frozen sections during radical prostatectomy, to exclude patients from non-curative surgery, and (2) as paraffin sections postoperatively from lymphadenectomy performed at radical prostatectomy, to stage the tumour and assess need for adjuvant treatment. Findings from the two approaches were used to assess the accuracy and cost of frozen section diagnosis, and to judge the results of omitting intraoperative diagnosis. RESULTS: In 82 patients frozen section revealed metastasis in six (7.3%), and metastases were found in a further four (4.9%) on paraffin sections (false negatives). Of the 195 patients undergoing staging lymphadenectomy (without frozen section), metastatic cancer was seen in nine cases (4.6%). The frozen section cost of metastatic cancer detection per patient was calculated as 7516 Pounds (550 Pounds x 82/6), with an associated false negative rate of 33%. CONCLUSIONS: Frozen section diagnosis of metastatic carcinoma in pelvic lymph nodes before radical prostatectomy has a high false negative rate and is costly. It may not be justified with the observed low incidence of lymph node metastasis.     

30例甲状腺乳头状癌术中冰冻切片诊断分析

目的探讨冰冻切片在甲状腺手术中的应用,并提高甲状腺乳头状癌冰冻切片诊断的准确率。方法回顾性对比观察我科室近10年30例甲状腺乳头状癌患者肿物冰冻切片和石蜡切片。结果冰冻切片诊断甲状腺乳头状癌23例,延迟3例,其他类型的疾病4例,假阴性诊断3例,冰冻切片确诊率为76.6%。结论正确的取材方法可提高对甲状腺乳头状癌的判别能力及甲状腺乳头状癌术中诊断的准确率,让冰冻切片在甲状腺肿术中发挥更加重要的作用。     

In breast cancer patients sentinel lymph node metastasis characteristics predict further axillary involvement

The aim of the study was to correlate various primary tumor characteristics with lymph node status, to examine sentinel lymph node (SLN) metastasis size and non-SLN axillary involvement, to look for a cut-off size/number value possibly predicting additional axillary involvement with more accuracy and to examine the relationship of SLN metastasis size to overall survival. Of 301 patients who underwent SLN biopsy, 75 had positive SLNs. The size of the metastases was measured. For different size categories, association with the prevalence of non-SLN metastases was assessed. Associations between metastasis size and tumor characteristics and overall survival (OS) were studied. The prevalence of axillary lymph node (ALN) involvement was not significantly different between cases with micrometastasis or macrometastasis in SLNs (p?=?0.124). However, for metastases larger than 6, 7, and 8 mm, the prevalence of ALN involvement was significantly higher (p?=?0.046, 0.022, and 0.025). OS was significantly lower in SLN-positive than in SLN-negative cases (p?=?0.0375). Primary tumor size larger than 20 mm was associated with a significantly higher incidence of SLN metastasis (p?<?0.001), and primary tumor size over 26 mm was associated with additional positive non-SLN (p?<?0.001). Higher mitotic index (≥7) in primary tumors was significantly (p?<?0.001) associated with ALN involvement in SLN-positive cases, whereas higher Ki67 labeling index was not significantly correlated with SLN or ALN involvement. Lymphovascular invasion (LVI) in primary tumors was significantly correlated with SLN positivity (p?<?0.001) but not with further ALN involvement or OS. Tumor size and LVI are predictive for SLN metastasis. Mitotic index, primary tumor size, and larger volume SLN involvement are determinants of further ALN involvement. SLN metastasis size over 6 mm is a strong predictor of further axillary involvement. OS is shorter in the presence of positive SLN.     

定量RT—PCR法检测乳腺癌前哨淋巴结CK19的研究

目的探讨定量RT—PCR法检测细胞角蛋白（CK19）在乳腺癌前哨淋巴结（SLN）中的表达，提高前哨淋巴结活检中微转移的检出率。方法采用常规病理检查法（HE染色）和定量RT—PCR法检测了40例乳腺癌患者SLN的CK19的表达量，同时选取10例来源于胃肠道的良性病变淋巴结作为定量RT—PCR检测的对照组。结果CK19在良性病变的淋巴结中没有表达。常规病理检查的敏感度为42．9％（9／21），假阴性为57．1％（12／21）．准确率为70．0％（28／40）。定量RT—PCR法检测出常规病理未检出的微小转移病例12例，敏感度为95．2％（20／21），假阴性为4．8％（1／21），准确率为97．5％（39／40）。结论前哨淋巴结活检可有效判断乳腺癌腋淋巴结转移状态，应用定量RT—PCR法检测CK19在SLN中的表达，可提高敏感度及准确率。     

Oestrogen receptor staining of paraffin-embedded breast carcinomas following short fixation in formalin: a comparison with cytosolic and frozen section receptor analyses

This paper describes an improved immunohistochemical method for demonstrating oestrogen receptor (OR) protein in paraffin-embedded sections of tissue fixed for 1.5 h in formalin. Thirty-two cases of infiltrating ductal breast carcinoma were stained with a monoclonal anti-OR antibody (H222), using a standard streptavidin-biotin method, following pretreatment with pronase. OR counts in paraffin sections were compared with those of frozen sections and with cytosolic values determined by a dextran-coated charcoal method. Twenty-seven of the carcinomas were OR-positive in paraffin sections. There was concordance between the paraffin section and the frozen section-determined receptor status in 30 cases (94 per cent) and a strong correlation was observed (r = 0.76; P less than 0.0001). Similarly, OR counts in paraffin sections correlated with cytosolic OR values (r = 0.60; P less than 0.001) and there was concordance in 97 per cent of cases. The percentage of positively-stained tumour cells in paraffin sections ranged from 0 to 94 per cent with staining intensities comparable to those seen in frozen sections. Staining of paraffin sections identified more OR-positive tumours than either frozen section staining or cytosolic assay. This study validates immunohistochemical OR analysis in formalin-fixed, paraffin-embedded breast carcinomas using a commercial anti-OR antibody.     

Multiparameter flow cytometry as a tool for the detection of micrometastatic tumour cells in the sentinel lymph node procedure of patients with breast cancer

AIM: To investigate whether multiparameter flow cytometry (MP-FCM) can be used for the detection of micrometastasis in sentinel lymph nodes (SLNs) in breast cancer. METHODS: Formalin fixed, paraffin wax embedded sentinel lymph nodes (n = 238) from 98 patients were analysed. For each lymph node, sections for haematoxylin and eosin (H&E) staining and immunohistochemistry (IHC) for cytokeratin (MNF116) were cut at three levels with a distance of 500 microm. The intervening material was used for MP-FCM. Cells were immunostained with MNF116, followed by an incubation with fluorescein isothiocyanate (FITC) labelled goat antimouse immunoglobulin. DNA was stained using propidium iodide. From each lymph node 100,000 cells were analysed on the flow cytometer. RESULTS: Thirty eight of the 98 patients with breast carcinoma showed evidence of metastatic disease in the SLN by one ore more of the three methods. In 37 of 38 cases where metastatic cells were seen in the routine H&E and/or IHC, more than 1% cytokeratin positive cells were detected by MP-FCM. In 24 patients, metastatic foci were more than 2 mm (macrometastasis) and in 14 these foci were smaller than 2 mm (micrometastasis). In three of these 14 cases, MP-FCM revealed positive SLNs, although this was not seen at first glance in the H&E or IHC sections. After revision of the slides, one of these three remained negative. However, MP-FCM analysis of the cytokeratin positive cells showed an aneuploid DNA peak, which was almost identical to that of the primary breast tumour. Duplicate measurements, done in 41 cases, showed a 99% reproducibility. In five of 14 patients with micrometastasis, one or two metastatic foci were found in the non-SLN. However, in 15 of 24 macrometastases multiple non-SLNs were found to have metastatic tumour. All micrometastases except for the remaining negative one mentioned above showed only diploid tumour cells, despite the fact that their primary tumours contained both diploid and aneuploid tumour cells. In primary tumours with more than 60% aneuploid cells, predominantly aneuploid macrometastasis were found, whereas diploid primary tumours only showed diploid micrometastases or macrometastases in their SLN. Aneuploid SLN macrometastases were associated with non-SLN metastases in five of seven patients, whereas diploid cases showed additional non-SLN metastases in only seven of 16 patients. CONCLUSION: In all cases, MP-FCM was sufficient to detect micrometastatic tumour cells in a large volume of lymph node tissue from SLNs. In some cases it was superior to H&E and IHC staining. Approximately 30% of SLN micrometastases are accompanied by additional non-SLN metastases. The size of the aneuploid fraction (> 60%) in the primary tumour may influence the risk of having both SLN and non-SLN metastases.     

Schnellschnitttelepathologie im klinischen Alltag eines Brustzentrums

For an intraoperative frozen section service, the period from surgeon's sample excision to the time of transmitting the diagnosis by the pathologist, should not last longer than 20 min. In a period of 16 months we performed 389 frozen sections by telepathology (298 patients) in our breast cancer center, using the Leica telepathology system (TPS 1.5). In 173 out of the 389 sections, an invasive carcinoma was diagnosed (312 frozen sections with the aim to verify malignancy and 77 to verify a tumor-free retroareolar resection margin). The overall error rate amounted to 7 out of 389 sections (about 2%; false-negative in 5 cases, false-positive in 2 cases) and is equivalent to the error rate without telepathology. The mean time for diagnosis per case was 15 min. For the future, it is desirable that hospitals without their own pathologists also perform frozen sections within an adequate time by using telepathology systems.     

Frozen section diagnosis for axillary sentinel lymph nodes: the first six years.

Intraoperative frozen section of axillary lymph nodes for the detection of metastatic breast cancer has been controversial because of the labor-intensive techniques necessary to obtain a highly sensitive test, and because of the uncertain significance of frequently detected submicrometastatic carcinoma. In total, 874 consecutive axillary sentinel lymph node cases examined by intraoperative frozen section over a 6-year period were reviewed retrospectively. Frozen section had a sensitivity of 60% and was 100% specific, but when cases with submicrometastatic tumor cells were considered negative, the sensitivity rose to 83%. Rare cases were called 'atypical' on frozen section; almost all of these cases were negative for carcinoma on permanent sections.     

Sentinel lymph nodes for breast carcinoma: an update on current practice

Sentinel lymph node (SLN) biopsy has been established as the standard of care for axillary staging in patients with invasive breast carcinoma and clinically negative lymph nodes (cN0). Historically, all patients with a positive SLN underwent axillary lymph node dissection (ALND). The ACOSOG Z0011 trial showed that women with T1–T2 disease and cN0 who undergo breast‐conserving surgery and whole‐breast radiotherapy can safely avoid ALND. The main goal of SLN examination should be to detect all macrometastases (>2 mm). Gross sectioning of SLNs at 2‐mm intervals and microscopic examination of one haematoxylin and eosin‐stained section from each SLN block is the preferred method for pathological evaluation of SLNs. The role and timing of SLN biopsy for patients who have received neoadjuvant chemotherapy is controversial, and continues to be explored in clinical trials. SLN biopsies from patients with invasive breast carcinoma who have received neoadjuvant chemotherapy pose particular challenges for pathologists.     

卵巢交界性肿瘤术中冷冻切片诊断的准确性分析

目的 评价卵巢交界性肿瘤(BTO)冷冻诊断的准确性和阳性预测值.方法 回顾性分析1995年3月至2008年5月广东省人民医院病理科诊断的BTO病例,单因素和多因素回归分析方法 用于评价患者及肿瘤特征对于不当诊断(低诊断和过诊断)的影响.结果 共有73例BTO患者入组,其中39例(53.42%)为浆液性肿瘤,32例(43.84%)为黏液性肿瘤,2例(2.74%)为宫内膜样肿瘤.冷冻诊断与石蜡诊断一致者为55/73(75.34%),冷冻诊断BTO的敏感性为87.30%,阳性预测值为85.94%.冷冻过诊断率为0,低诊断率为24.66%(18/73).在单因素分析中,肿瘤直径和肿瘤组织学类型与冷冻低诊断有关;在多因素回归分析中,肿瘤直径是预测低诊断的惟一自变量.而患者年龄、肿瘤分期、双侧卵巢肿瘤、血清CA-125和子宫内膜异位与冷冻低诊断无关.结论 术中冷冻诊断BTO的敏感性和阳性预测值较低,低诊断常常发生,外科医师应对BTO的冷冻诊断持谨慎态度.     

乳腺癌术中前哨淋巴结169枚印片细胞学诊断分析

目的探讨印片细胞学检查在乳腺癌术中前哨淋巴结诊断的价值,提高术中快速诊断的准确率。方法对67例乳腺癌患者的169枚前哨淋巴结同时进行术中冷冻切片检查及印片细胞学检查,与术后石蜡切片诊断对比分析。结果以淋巴结枚数为单位,169例术中前哨淋巴结冷冻切片确诊163例,确诊率96.45%;印片细胞学确诊162例,确诊率95.86%;两者联合诊断,共同确诊166例,确诊率98.22%。结论乳腺癌术中前哨淋巴结印片细胞学检查与冷冻切片检查相结合有互补作用,联合应用可提高术中前哨淋巴结诊断准确率。     

The extent of agreement between frozen and paraffin block data from axillary samples in patients with early-stage breast cancer

IntroductionPatients with early-stage breast cancer currently undergo sentinel lymph node dissection to evaluate the axillary region. Frozen tissue blocks are evaluated intra operatively and paraffin-embedded samples are studied postoperatively. We explored whether sentinel lymph node dissection adequately reflected axillary involvement (as revealed by the paraffin blocks) in patients with early-stage breast cancer; we sought to avoid axillary dissection.MethodsThe agreement/non-agreement rates between the results of axillary ultrasonography and biopsy, sentinel lymph node and axillary dissections, and frozen and paraffin block results, were retrospectively analyzed for 200 patients with early-stage breast cancer. The positive predictive values and accuracies were recorded in those who were positive on both ultrasonography and biopsy. The negative predictive values were calculated for doubly negative cases.ResultsThe frozen and paraffin block results disagreed in 19 (9.5 %) cases and agreed in 181 (90.5 %). The frozen block and dissection results differed in five of 38 patients who underwent axillary dissection (AD) (one patient did not undergo AD); the results were in agreement in 32. Of the 19 block-disagreement cases, 16 were in the non-neoadjuvant chemotherapy (NAC) group and three in the NAC treatment group. Clinically, the negative predictive values of the frozen and paraffin block data were 80 % in patients lacking axillary involvement.ConclusionParaffin block evaluations only (thus, without frozen block examinations) of early-stage breast cancer lymph nodes seem to be sufficient to guide treatment. Also, a thorough clinical examination (with ultrasonography and axillary biopsy) reduces the dissection rate and the associated functional impairments.     

Interinstitutional comparison of frozen-section consultation. A College of American Pathologists Q-Probe study of 79,647 consultations in 297 North American institutions.

In 1989, the College of American Pathologists Q-Probes Quality Assurance Program studied intraoperative frozen-section consultations performed in 297 institutions with mean bed size of 316 (range, 0 to 1351 beds) in North America during 5 consecutive months. The aggregate database was composed of 933,751 surgical cases (mean, 3144 per institution); 52,464 frozen-section cases (mean, 177); and 79,647 individual frozen sections performed (mean, 268). The rate of frozen sections per all surgical case accessions was 5.6% (cases with frozen section) and 7.3% (individual frozen sections performed), with an average of 1.5 frozen sections per case. Frozen-section rate increased proportional to bed size, from less than 5% in institutions with bed size below 150 to 15% in institutions with bed size above 600. Of all frozen sections performed, 4.2% were deferred. Deferrals to paraffin sections in pathologists' opinions were 92.6% appropriate, 1.2% inappropriate, and 6.2% not stated. When frozen-section diagnoses were compared with permanent section diagnoses, there was a 98.3% diagnostic concordance, adjusted for deferred diagnoses, but including the performance of frozen sections on mammographically directed biopsy specimens with no gross abnormalities in 80% of institutions. This practice accounted for 11.8% of the discordant frozen-section diagnoses. The reasons for diagnostic discordances were gross tissue sampling (44.8%); misinterpretation (40%); sectioning (12.7%); inadequate history (5.6%); staining (1.5%); labeling (0.5%); and other (3%). Assessment of diagnostic discordance on patient outcomes by the reviewing pathologist showed that patient management was unaffected in 74%, minimally affected in 20%, and greatly affected in 2.5%.