A Practical Approach to Intraoperative Consultation in Gynecological Pathology

Abstract

The use of frozen section in gynecological pathology has not been emphasized in the literature to the same degree as in other surgical fields. This review focuses on the indications, contraindications, and limitations of frozen-section diagnosis specific to the female genital tract. An intraoperative consultation in gynecological pathology is indicated (a) to ensure that the tissue sampled is adequate for diagnosis, (b) to determine the nature of a disease process, (c) to plan for appropriate ancillary studies, (d) to determine tumor spread, and (e) to assess the margins. In the ovary, mucinous tumors in particular may present a challenge and potential for misdiagnosis at the time of frozen section. It is important to determine the nature of the ovarian involvement, as tumor size greater than 10 cm or bilateral involvement strongly suggests a metastatic process. Also, the distinction between ovarian carcinoma and tumors of borderline malignancy may be difficult in a limited sampling. In the germ cell category, an important distinction is that of a dysgerminoma from a large cell lymphoma, due to different treatment regimes. Pregnant and postpartum women present a unique challenge as the effects of high levels of pregnancy-related hormones may result in lesions that closely mimic malignancy. Although intraoperative frozen section should be discouraged as a primary diagnostic procedure for endometrial carcinoma, it can be very helpful to identify those patients who are at risk for extrauterine spread and who may require lymphadenectomy. Analysis of a cone biopsy of the cervix by frozen section may be warranted particularly if the previous biopsy showed equivocal stromal invasion, an uncertain depth of invasion, there are issues related to fertility; however, the process is time consuming and may compromise the permanent sections if the lesion is very small. Frozen-section diagnosis in squamous cell carcinoma and in Paget disease of the vulva is infrequently requested as these entities are multifocal resulting in an inaccurate frozen-section diagnosis. Lastly, intraoperative evaluation of lymph nodes including the role of sentinel lymph nodes is discussed.