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Frozen cones: they have a niche
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Gynecologic Oncology 91 (2003) 279
www.elsevier.com/locate/ygyno
Editorial
Frozen cones: they have a niche Rapid frozen section interpretation of cervical conization specimens arouses strong visceral feelings in both gynecologic surgeons and pathologists. Opinions about the safety and utility of the procedure are often formed from eminence-based rather than from evidence-based medicine. In this issue of Gynecologic Oncology, Giuntoli et al. [1] report another clinical series investigating the role of frozen section in managing patients with cervical carcinoma. As their literature review indicates, there is already a significant published track record related to interpretation of frozensection-processed tissue from patients with early cervical squamous neoplasia. Their review reemphasizes the surgical pathologist’s ability to consistently differentiate invasive from intraepithelial cervical squamous neoplasia on either frozen or paraffin-fixed tissue [2–5]. The controversy surrounding frozen section diagnosis of conization specimens has never really been about accuracy. Like much else in life, the issues are time and money. The advantages of diagnosis from frozen section are related to anesthetic administration, convenience, and scheduling. If a patient requires conization under anesthesia, it is clearly in her best interests to receive definitive therapy with a single anesthetic. If a patient is required to travel great distances or has significant time and schedule limitations, therapy based on frozen section is a blessing. The cost of preparation and interpretation of frozen section material is related to the number of blocks processed. The cost issue fades when compared to the costs of second anesthetic. Some feel that the prolonged wait— often from 45 minutes to an hour, with a patient anesthetized while the pathologist evaluates the frozen section—negates any advantage. This wait is related to the traditional approach to frozen section diagnosis of microinvasive cancer. Previous investigators have felt that one should not try to quantitate the depth of cervical stromal invasion on frozen tissue when the depth is less than the depth used to define frank invasion, i.e., 3 mm. Definitive diagnosis (and presumably definitive treatment) of microinvasive cervical cancer should be deferred until after the evaluation of paraffinfixed tissue. This policy leads to prolonged intraoperative waiting. Pending final disposition, no definitive operation should be performed. Because of this possibility, the time in the operating room is spent waiting, not operating. 0090-8258/$ – see front matter © 2003 Elsevier Inc. All rights reserved.
The demonstration by Giuntoli et al. that a surgical pathologist can accurately quantitate the depth of stromal invasion on frozen tissue bears directly on the issue of time. Whether the frozen-section-assisted diagnosis is intraepithelial neoplasia, microinvasion, or frank invasion, surgical treatment can be initiated after the removal of the conization specimen. The initial surgical steps of simple hysterectomy and radical hysterectomy are similar. Frozen section diagnosis will usually be available before a sfpoint in the case that commits the surgeon to a radical procedure. A tailored treatment disposition based upon an accurate, reproducible pathologic diagnosis is possible. As noted by the authors, these findings apply only to early squamous cervical neoplasia. Based on available data, the diagnosis of microinvasive adenocarcinoma of the cervix should be deferred until after examination of paraffin-fixed material. Outpatient diagnostic loop diathermy of the cervix has replaced the need for most surgical conizations. The demonstration, again, of the diagnostic accuracy of diagnoses made from frozen section material gives the busy surgeon, and the busy patient, another treatment option. Edward V. Hannigan, M.D. University of Texas Medical Branch at Galveston 301 University Boulevard Galveston, TX 77555, USA E-mail address: [email protected] doi:10.1016/S0090-8258(03)00657-7 References [1] Giuntoli RL, Winburn KA, Silverman MB, Keeney GL, Cliby WA. Frozen section evaluation of cervical cold knife cone specimens is accurate in the diagnosis of microinvasive squamous cell carcinoma. Gynecol Oncol 2003;. [2] Guerriero WF, Cox R, Tillery W, Race GJ. Clinical value of the cryostat frozen section in the diagnosis of cervical carcinoma. Obstet Gynecol 1964;24:61–5. [3] DiMusto JC. Reliability of frozen sections in gynecologic surgery. Obstet Gynecol 1970;35:235– 40. [4] Woodruff JD, Baggish MS, Kooyman DB. The cryostat cone for rapid diagnosis in carcinoma of the uterine cervix. Md State Med J 1970;19:64–8. [5] Hannigan EV, Simpson JS, Dillard EA Jr, Dinh TV. Frozen section evaluation of cervical conization specimens. J Reprod Med 1986;31:11– 4.
Gynecologic Oncology 91 (2003) 279
www.elsevier.com/locate/ygyno
Editorial
Frozen cones: they have a niche Rapid frozen section interpretation of cervical conization specimens arouses strong visceral feelings in both gynecologic surgeons and pathologists. Opinions about the safety and utility of the procedure are often formed from eminence-based rather than from evidence-based medicine. In this issue of Gynecologic Oncology, Giuntoli et al. [1] report another clinical series investigating the role of frozen section in managing patients with cervical carcinoma. As their literature review indicates, there is already a significant published track record related to interpretation of frozensection-processed tissue from patients with early cervical squamous neoplasia. Their review reemphasizes the surgical pathologist’s ability to consistently differentiate invasive from intraepithelial cervical squamous neoplasia on either frozen or paraffin-fixed tissue [2–5]. The controversy surrounding frozen section diagnosis of conization specimens has never really been about accuracy. Like much else in life, the issues are time and money. The advantages of diagnosis from frozen section are related to anesthetic administration, convenience, and scheduling. If a patient requires conization under anesthesia, it is clearly in her best interests to receive definitive therapy with a single anesthetic. If a patient is required to travel great distances or has significant time and schedule limitations, therapy based on frozen section is a blessing. The cost of preparation and interpretation of frozen section material is related to the number of blocks processed. The cost issue fades when compared to the costs of second anesthetic. Some feel that the prolonged wait— often from 45 minutes to an hour, with a patient anesthetized while the pathologist evaluates the frozen section—negates any advantage. This wait is related to the traditional approach to frozen section diagnosis of microinvasive cancer. Previous investigators have felt that one should not try to quantitate the depth of cervical stromal invasion on frozen tissue when the depth is less than the depth used to define frank invasion, i.e., 3 mm. Definitive diagnosis (and presumably definitive treatment) of microinvasive cervical cancer should be deferred until after the evaluation of paraffinfixed tissue. This policy leads to prolonged intraoperative waiting. Pending final disposition, no definitive operation should be performed. Because of this possibility, the time in the operating room is spent waiting, not operating. 0090-8258/$ – see front matter © 2003 Elsevier Inc. All rights reserved.
The demonstration by Giuntoli et al. that a surgical pathologist can accurately quantitate the depth of stromal invasion on frozen tissue bears directly on the issue of time. Whether the frozen-section-assisted diagnosis is intraepithelial neoplasia, microinvasion, or frank invasion, surgical treatment can be initiated after the removal of the conization specimen. The initial surgical steps of simple hysterectomy and radical hysterectomy are similar. Frozen section diagnosis will usually be available before a sfpoint in the case that commits the surgeon to a radical procedure. A tailored treatment disposition based upon an accurate, reproducible pathologic diagnosis is possible. As noted by the authors, these findings apply only to early squamous cervical neoplasia. Based on available data, the diagnosis of microinvasive adenocarcinoma of the cervix should be deferred until after examination of paraffin-fixed material. Outpatient diagnostic loop diathermy of the cervix has replaced the need for most surgical conizations. The demonstration, again, of the diagnostic accuracy of diagnoses made from frozen section material gives the busy surgeon, and the busy patient, another treatment option. Edward V. Hannigan, M.D. University of Texas Medical Branch at Galveston 301 University Boulevard Galveston, TX 77555, USA E-mail address: [email protected] doi:10.1016/S0090-8258(03)00657-7 References [1] Giuntoli RL, Winburn KA, Silverman MB, Keeney GL, Cliby WA. Frozen section evaluation of cervical cold knife cone specimens is accurate in the diagnosis of microinvasive squamous cell carcinoma. Gynecol Oncol 2003;. [2] Guerriero WF, Cox R, Tillery W, Race GJ. Clinical value of the cryostat frozen section in the diagnosis of cervical carcinoma. Obstet Gynecol 1964;24:61–5. [3] DiMusto JC. Reliability of frozen sections in gynecologic surgery. Obstet Gynecol 1970;35:235– 40. [4] Woodruff JD, Baggish MS, Kooyman DB. The cryostat cone for rapid diagnosis in carcinoma of the uterine cervix. Md State Med J 1970;19:64–8. [5] Hannigan EV, Simpson JS, Dillard EA Jr, Dinh TV. Frozen section evaluation of cervical conization specimens. J Reprod Med 1986;31:11– 4.