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Frozen section diagnosis in ophthalmic surgery
SURVEY
OF OPHTHALMOLOGY
DIAGNOSTIC MORTON F. GOLDBERG,
VOLUME 28.
NUMBER 4. JANUARY-FEBRUARY
1984
AND SURGICAL
TECHNIQUES
EDITOR
Frozen Section Diagnosis in Ophthalmic ZEYNEL A. KARCIOGLU,
M.D. AND DELMAR
R. CALDWELL,
Surgery M.D.
0 ‘Brien Ocular Pathology Laboratory, Department of Ophthalmology, Tulane Medical Center, New Orleans, Louisiana
Abstract. Frozen section diagnosis can afford the opportunity for histopathological examination of excised tissues in the operating room. Because frozen section techniques have traditionally been little used in ophthalmic surgery, many pathologists are not familiar with eye tissues. However, with cooperation and understanding between the ophthalmologist and the pathologist, frozen section diagnosis may be able to identify the tissue, the pathologic process and the extent of the lesion within l&15 minutes. In this review, applications and problems of frozen section diagnosis in various types ofocular surgery are discussed. (Surv Ophthalmol28:323-332, 1984)
Key words.
frozen
section
diagnosis
l
ocular
T
pathology
l
ocular
surgery
Howard A. Kelly. “’ It was not until after 1905, when Louis B. Wilson of the Mayo Clinic published his method of staining frozen sections with methylene blue, that diagnosis during operation was accepted as a routine procedure. “’ Even after the method was widely accepted, many surgeons and pathologists were relucant to make much use of it for years. As recently as the 1950s obtaining fresh frozen section was a source of stress for surgeons and pathologists alike. The opening sentence in a paper by Malcolm Dockerty published in 1953 states that “the attitude of the busy pathologist responding to a hurried summons from the operating room for purposes of making a fresh frozen section was like his attitude toward court summons, one of distaste.“” Since then an entire generation of pathologists and surgeons have been trained in the use and interpretation of the frozen section. Many of the anxieties that plagued the pathologist when the technique was new and unfamiliar have been put aside and the frozen section is now available in most hospitals
here are few diagnostic techniques that can have such immediate and vital consequences to the patient as the frozen section diagnosis performed at the time of surgery. In order to he of use, the frozen section must be reliable and performed rapidly within 10-15 minutes. Today, the accuracy of frozen section diagnosis is reported to be 97-99 percentI and it is widely used in all surgical specialties. The use of frozen section originated in the late 19th century, following the invention of the freezing microtome. In 1891 William H. Welch examined a frozen section from a breast tumor which was being removed by W. S. Halstead. Welch’s technique was very slow and the surgeon completed the operation before the pathologist had finished the diagnostic examination. A more significant contribution was made at Johns Hopkins Hospital in 1895 when Thomas S. Cullen, a young instructor, devised a rapid method for making permanent frozen sections; this procedure became routine in the clinic of 323
324
Sure Ophthalmol
across
28(4) January-February
FALSE POSITIVE
the country.
Purpose There
and Pitfalls
is one
purpose
that is to determine the operating
room.
1) Identification gland
or lymph
of Frozen Section
in the
frozen
the surgeon’s This
section,
and
course
of action
(e.g.,
parathyroid
in
requires:
of the node?
tissue Iris
or retina?);
Identification of the pathologic process (inflammatory or neoplastic? benign or malignant?); and 3) Identification of the extent ofa lesion (surgical margin involved or free?). Certain generalizations can be made concerning the errors in frozen section diagnosis which are reduced to a minimum if all clinical information is available to the pathologist and if the frozen section technique is of high quality. Frozen section diagnosis is not a game to see whether the pathologist can make the diagnosis without any history. At times the patient may have had previous surgery and this material should be obtained and studied in advance by the pathologist. The pathologist should enter the operating room and look at the lesion in situ to make suggestions as to the way the biopsy should be taken. It is ideal to have an experienced pathologist who is conservative in attitude and, most important, who is familiar with the clinical setting to havejudgment of a given case. If the pathologic process cannot be identified, the pathologist must be honest enough to say that he/she is unable to make a diagnosis. It may be necessary to request additional tissue or defer the diagnosis until the permanent sections are prepared. But, in practically all instances a decision must be made; otherwise the pathologist’s value to the surgeon is tremendously diminished. It is essential that both the clinician and the pathologist be aware of the limitations of this diagnostic procedure. The errors of frozen section can be grouped under two main categories - false negative and false positive diagnosis. 2)
FALSE NEGATIVE
KARCIOGLU
1984
DIAGNOSIS
False negative diagnosis most often occurs if the material is not properly selected for frozen section. It may be thought that the material is representative but no significant pathologic findings are observed. Later, when all of the material is reviewed in permanent sections, an area of previously unsuspected pathology may be found. This indicates how imperative it is that the material for frozen section be selected with the greatest of care. False negative errors may also be associated with negative misinterpretation of tumor at margins of resection. As a result of this, of course, tumor tissue is left behind.
AND CALDWELL
DIAGNOSIS
False positive diagnosis occurs due to misinterpretation of the histopathologic process. The erroneous diagnosis of an inflammatory reaction as tumor infiltrate or of a benign tumor as malignant are examples of false positive errors. At times this may lead to disastrous results, e.g., removal of a healthy organ which was presumed to contain a malignant tumor. When a false positive diagnosis is made to determine the adequacy of a surgical excision the consequences are less serious, but, nevertheless, it leads to additional and unnecessary tissue removal.
Frozen Section Diagnosis Surgery
In Opthalmic
Because traditionally ophthalmic frozen section requests have been rare, pathologists in many hospitals are not familiar with eye surgery material. It may very well be a horrifying experience for a general surgical pathologist to face a 1.O X 1.O mm fragment of pupillary membrane and be asked whether this represents an epithelial downgrowth or something else. On the other hand, when the procedure is done by an ocular pathologist or by a pathologist who has interest in ophthalmic surgery, frozen section offers valuable information to the eye surgeon in many cases (Table 1). Percentage of accurate diagtiosis of ophthalmic surgery material is difficult to assess because of the small number of cases; in our experience, however, the accuracy is close to 97%.
TABLE
1
Frozen Section Diagnoses on Ophthalmic Surgery Material O’Brien Ocular Pathology Laboratory Eyelids and Conjunctiva
Basal cell carcinoma with margins Actinic keratosis Squamous papilloma Squamous cell carcinoma with margins Pterygium Conjunctival melanoma Lacrimal
Gland and Lacrimal
Inverted
(Schneiderian)
Drainage
System
papilloma
Anterior segment
Anterior segment membranes Metastatic iris tumor Primary melanoma of iris with margins Orbit
Hemangioma (capillary and cavernous) Lymphoma Ectopic lacrimal gland tissue Choroidal melanoma extension Granulomatous inflammation Squamous cell carcinoma extension Pseudotumor Granular cell tumor Retinoblastoma in optic nerve
from
FROZEN
SECTION
DIAGNOSIS
IN OPHTHALMIC
Fig. I. Simple labelling ofmargins for frozen section. With this method the margins of the excised specimen, not the margins of the remaining tissue, are examined. The deep margin can not be examined thoroughly; therefore, this technique should only be used for superficial lesions.
To obtain a maximum yield from any frozen section, certain technical points should be taken into account. Labeling of the lesion and margins should be done meticulously at the time of resection and should be simple and clearly understandable to the surgeon and pathologist. For small lesions it is best to have a simple diagram on the surgical drape and mark the margins on the diagram as the tissues are sent to the pathologist (Fig. 1). For more involved cases, it is best to work with a pathologist who can be actually present in the operating room to orient the tissues with reference to the excision site. Proper communication between the pathologist and surgeon improves the orientation and avoids frustratconversations.” ing “intercom Tissues removed for frozen section examination should be handled delicately to avoid crush arte-
325
SURGERY
facts. Care should be taken to insure that the specimens are obtained with blades and should include the full thickness of the tissue. Considering that the frozen section material in ophthalmic surgery consists of small pieces of tissue, even the slightest rough handling may result in crush artefacts which in turn produce misleading results. For example, a small cluster of crushed chronic inflammatory cells may easily be diagnosed as a focus of infiltrating tumor (Fig. 2). The frozen section specimen should not be cauterized or photocoagulated under any circumstances. Cauterized tissue is worthless for histologic interpretation. The disadvantages of tissue damage secondary to CO, laser application has been well documented by Peyman and co-workers in a recent case of uveal melanoma.“’ A point commonly overlooked by the inexperienced surgeon is that the margins of the tissue remaining around the area of tumor involvement should not be cauterized until the previously submitted tissue is proven to be free of tumor (Fig. 3). Otherwise, the adjacent layer of tissue from the questionable margin will contain severe cauterization artefacts. This becomes particularly important when one is dealing with the deep margin of the resection which is usually the subcutaneous adipose tissue. EYELIDS
AND CONJUNCTIVA
Frozen section is used to identify the nature of many eyelid lesions and also to determine the extent of disease. Although the location and other clinical features of many lesions give an idea about its nature, the ultimate diagnosis should always be based on histopathologic examination. Basal cell carcinoma accounts for approximately 90% of all malignant tumors of the eyelid.‘.” These tumors can be classified in four basic histologic
Fig. 2. A focus of inflammatory tissue with crush artefact. No cellular detail can be obtained from distorted tissue.
326
Surv Ophthalmol
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1984
Fig. 3. A: Frozen section sample removed from Area B. B = Margin of remaining tissue. C = Margin of the sample corresponding to Area B. Area cauterized until Area C is proven to \\‘hen sample A is submitted for frozen of cardboard, Area C should face down tation. (For all practical purposes Area sion margin of Area B.)
B should be free of section on for proper C represents
not be tumor. a piece orienexci-
types, namely superficial, nodular, ulcerating and morphea types. The biological behavior of basal cell carcinoma is correlated with its morphologic pattern and therefore the type of the neoplasm should be determined and the treatment should be planned accordingly. For the nodular type of basal cell carcinoma, the conventional sectioning of the skin ellipse would provide a great deal of information (Fig. 4) .’ Three full-thickness sections (A, B, and C) taken from the skin ellipse would reveal satisfactory information about the surgical excision margins. This can easily be done with frozen sections. If all margins are found to be involved, additional full-thickness sections from the area of concern should be submitted for frozen section. If the deep surgical margin reveals involvement with tumor, additional specimens should be obtained from the base. At this point it is very helpful to map the base of resection and code the additional layers of tissue with letters (Fig. 5). The true edges of the resections should be marked with india ink or with different colored dyes. Thus, the areas of the residual tumor are easily marked on the map and only those areas are subsequently excised. This mapping identifies the exact location of the residual tumor and uninvolved tissue can be spared. Surgical resection is continued until there is a histologically proven tumor-free plane. The method described here is the simplest and most practical way of allowing a three-dimensional tracing of the entire tumor field which is within the means of any surgical pathology laboratory. This technique is the basis of Mohs’ chemosurgery.‘4 Mohs’ original technique utilized tissue fixation which facilitated accu-
KARCIOGLU
AND CALDWELL
rate histopathology but was caustic. The irritating nature of the zinc chloride proved to be a big disadvantage, particularly for eyelid lesions.“j To avoid the irritation, Mohs’ fresh tissue concept has been developed and proved to be the most efficacious technique for removal of skin neoplasms.‘,‘” One should realize that its accuracy depends entirely on the tissue sectioning methods, proper mapping of the surgical field and histopathologic interpretation. As was originally pointed out by Mohs and Lathrop, this histographic excision technique has proven to offer exceptional cure rates for certain types of epithelial neoplasms.‘~‘“,” In a series of 7000 basal cell carcinomas and over 2500 squamous cell carcinomas of skin treated with chemosurgery, Mohs reported 5-year survival rates of 99.3% and 94.4% respectively.‘” Mohs’ technique is not necessary in many cases of nodular basal cell carcinoma. The ulcerating, superficial and morphea types, however, are eficiently treated with this method. It is particularly useful for the medial canthus lesions and for those which are larger than 2 cm in diameter. Furthermore, the histographic excision technique produces excellent results in lesions with history of previous treatment and aggressive infiltrative character.2’ These tumors usually contain excessive amounts of fibrous tissue and extend fingerlike projections along tissue planes instead of maintaining regular growth patterns. The greatest advantage of this technique is the frozen section examination of the margins of remaining tissue rather than the margins of the excised specimen. Removal of multiple thin layers from the base of the excision, as described earlier in this review, is based upon the same principle. It is now agreed beyond any doubt that the histographic excision technique with frozen sections (Mohs or otherwise) markedly reduces recurrences and allows maximum preservation of normal tissue, as compared to any other surgical method. The limitations of this technique, however, should also be observed. When the tumor invades the orbital tissues, it becomes extremely difficult to map the areas of involvement and orient the sections for histopathologic evaluation. Consequently, the accuracy of the technique suffers considerably when one is dealing with invasive carcinoma of orbital soft tissues. It is ideal for orientation to place the full-thickness section on a piece of cardboard, the surgical excision margin facing down (Fig. 3). Furthermore, Iateral margins can be specified on the cardboard, i.e., temporal, nasal, etc. Curettage material of basal cell carcinoma is sometimes adequate for histologic study but usually is a poor specimen for frozen section diagnosis.
FROZEN SECTION DIAGNOSIS
IN OPHTHALMIC
SURGERY
327
Fig. 5. Histographic excision technique. This method offers the frozen section examination of the margins of the remaining tissue, not the margins of excised specimen. Sections a, b, c, d, e, etc. at every level (L 1,2,3, etc.) may be examined individually or may be combined to obtain larger pieces of tissue. Note that Area b at level 3 contains tumor.
Fig. 4. Conventional sectioning of a skin ellipse with nodular lesion. Sections A, B and C are sufficient to cover lateral and deep margins.
The techniques described above for diagnosing basal cell carcinoma are also quite satisfactory for other skin neoplasms of the eyelids and the periorbital region. The specimens taken from questionable squamous cell carcinomas should represent a fullthickness section of the skin to determine the depth of invasion. This is also helpful to rule out the possibility of a subepithelial lesion causing pseudocarcinomatous hyperplasia of the epithelium.’ Lesions suspected of being melanomas require meticulous techniques of biopsy. In a suspicious lesion the histologic diagnosis must be firmly established before definitive, sometimes mutilating surgery is undertaken. The biopsy should be done preferably in tolo of the grossly visible lesion with a depth extending into the subcutaneous fat. Although frozen sections can be processed at the time of surgery, it is best to base the diagnosis on permanent sections for optimal interpretation. Sebaceous gland carcinoma of the eyelid may histologically mimic many neoplastic and inflammatory lesions including squamous cell carcinoma, basal cell carcinoma, metastatic tumors, melanoma and chalazion. The difficulties in the diagnosis and
the pitfalls involved have been well documented in the literature.“.” Therefore, we are often reluctant to attempt such evaluations based on frozen section diagnosis. Sebaceous gland carcinoma with Pagetoid spread can easily be misinterpreted as squamous cell carcinoma-in-situ, as reported by Leibsohn et al.” Even in paraffin sections, this Bowenoid-like histology may be very difficult to evaluate without a full-thickness eyelid biopsy (Fig. 6). A misdiagnosis of melanoma or metastatic carcinoma may also be encountered. One of the authors (ZAK) has witnessed a case of an early sebaceous gland carcinoma which was misinterpreted as metastatic renal cell tumor in a patient who had undergone nephrectomy years earlier for renal cell carcinoma. Metastatic renal cell carcinoma, in general, can be extremely difficult to diagnose because of the unpredictable pattern of metastasis. Metastatic disease can present at any time, occasionally after decades of diagnosis of primary carcinoma, or may precede the recognition of the primary tumor.” Frozen section may be useful to diagnose a number of conjunctival lesions such as dermoid, hemangioma and lymphangioma, old organized hematoma, pinguecula and pterygium, dysplastic and neoplastic epithelial lesions and some stromal neoplasms.
328
Surv Ophthalmol
28(4) January-February
1984
KARCIOGLU
AND CALDWELL
Fig. 6. Pagetoid involvement of conjunctival epithelium by sebaceous gland carcinoma (arrows).
One technical problem related to conjunctival and cornea1 frozen section biopsies is the thinness of the tissue. This becomes particularly important when superficial premalignant lesions, such as squamous cell carcinoma in situ, or acquired precancerous melanosis is involved. At the time of frozen section the specimen should be serially sliced to examine the full thickness of the epithelium and the depth of invasion if there is any. If the adequacy of surgical margins is going to be determined it is best that the specimen is mounted on a piece of cardboard as shown in Fig. 7 for proper orientation. LACRIMAL DRAINAGE
GLAND AND LACRIMAL SYSTEM
Frozen section diagnosis can be useful in evaluating disorders of the lacrimal system. Approximately one-half of lacrimal gland tumors are epithelial in origin and the other half consists of inflammatory pseudotumors. The determination of the inflammatory versus neoplastic nature of the disease process by frozen section at the time of surgery can be extremely useful. Most commonly encountered epithelial tumors of the lacrimal gland, namely pleomorphic adenoma and adenoid cystic carcinoma, can be easily diagnosed with frozen section. Other types of adenocarcinoma, however, may be difficult to differentiate from chronic dacryoadenitis and inflammatory pseudotumors. A longstanding chronic inflammation with extensive fibrosis can alter the normal architecture of the lacrimal gland and distort the acinar pattern to mimic infiltrating adenocarcinoma. Therefore, for a questionable lacrimal gland lesion, or for a patient on whom extensive surgery is planned, it is safer to base the diagnosis
on permanent paraffin sections. Predominantly lymphocytic lesions of the lacrimal gland which are similar to lymphocytic inflammatory pseudotumor of the orbit are difficult to study with frozen sections. Therefore, it is best not to rely on frozen section diagnosis of lymphocytic lesions in the lacrimal gland region or elsewhere in the orbit. Granulomatous lesions of the lacrimal gland such as sarcoidosis, on the other hand, can easily be detected on frozen sections. Frozen sections may also be useful to identify lacrimal drainage system papillomas and carcinomas. Because of the multifocal nature of the carcinomatous changes within the papillomata of the lacrimal drainage system, one cannot rule out malignancy with one or two sections of a given tumor. Inverted (Schneiderian) papillomas of this region almost always present a certain degree of cellular atypia in certain zones of the tumor.” This atypical change may be a major pitfall at the time of frozen section examination and these areas may be over-called as carcinoma in fita. A frankly invasive squamous cell carcinoma, however, originating in this region, can easily be diagnosed with frozen section and in the majority of instances a frozen section becomes a very valuable tool to evaluate the margins of resection. Lacrimal drainage system casts which are formed by proliferation of actinomyces represent another type of pathology which can be diagnosed on frozen section. ANTERIOR
SEGMENT
Frozen section to the ophthalmic
examination also offers some help surgeon in intraocular procedures
FROZEN
SECTION
DIAGNOSIS
IN OPHTHALMIC
SURGERY
329
/rw ,, ,,j /. z
,,’
,2,h&,,
Fig. 8. Idcal
orientation
,’
,“”
of iris lesion on a piece of card-
1)oard. l:ig. 7. Ideal
orientation
of’ con,junctival
lesion
on a piece
of cardboard.
ofthe anterior
segment.
In our institution,
question-
for frozen section to distinguish epithelial downgrowth from fibrous proliferation. In one case, the section from one of these membranes was proven to contain retinal tissue. Utilization of frozen section diagnosis has also been suggested to identify retinal tissue outside of the globe in severe trauma cases.’ The membrane specimens are usually very small and at times are difficult to section in a cryo block. It may be preferable to spread these small fragments directly on a glass slide and stain them with quick stains such as methylene blue. If the specimen does not stick on the slide, a small amount of glycerin solution can he applied as a base or a granular glass slide can he used. The folded parts of the tissue are difficult to examine, therefore it is very important that these membranes are flatly spread over the glass slide. Frozen section is helpful in identifying tumor and tumor-like lesions of the iris. Although the melanotic tumors can be diagnosed in frozen section specimens in many instances, several pitfalls should be taken into consideration. In heavily pigmented tumors it may be difficult to differentiate between melanoma cells and pigment laden macrophages. Recurrent and residual iris tumors are also difficult to evaluate on frozen section material because of the presence of fibrosis and secondary inflammatory changes of initial surgery. Frozen section examination can be very useful in determining the surgical resection margin of any iris tumor. Following removal, the excised iris and tumor tissue tend to curl and become distorted. At this point it may be dificult for the pathologist to study the excision margin of the tumor. The best method of orientation is to place this specimen on a piece of cardboard with a able anterior
segment
membranes
are submitted
simple drawing indicating the clock hours (Fig. 8). In cases where the iris lesion extends toward the base of the iris, the evaluation of the excision margin becomes particularly difficult. Ideally, in difficult cases the pathologist will be present in the operating room at the time of surgery, thus enabling him to orient the specimen according to his needs. N’hen interpreting iris nodules on frozen section, one should not be influenced by the clinical diagnosis and should remember that many lesions may be mistaken clinically for melanoma of the iris.” In Ferry’s clinicopathologic study of 69 eyes enucleated with clinical diagnosis of melanoma of the iris, no tumor was present in 24 eyes (35%). His study was done in 1965 and included old material from AFIP tiles, but even today one should always remember that a number of iris lesions may mimic melanoma clinically and histologically {Table 2). ,4n example of this problem is depicted in Fig. 9 which was obtained from an iris nodule. A definitive differential between melanoma and metastatic tumor could not be made on frozen sections. Only after permanent preparations with special stains were available did it become clear that the lesion represented a meta-
TABLE Lh@rential
Diagnosis
Clinical :\nterior staphyloma Inflammatory mass (pseuin anterior dotumor) chamber Juvenile xanthogranuloma Cysts in anterior chamber Stromal atrophy of the iris Postoperative scar of iris Foreign body in iris Hematoma in iris Nexus and melanocytoma Metastatic tumor
2 oy Iris .2lelanoma
Histopathologic News Melanocytoma Inflammatory pigment
nodule with laden macro-
phages Hematoma with laden macrophages Metastatic tumor
pigment
Surv Ophthalmol
28(4) January-February
1984
KARCIOGLU
AND
CALDWELL
r;is. 9. Clusters of adenocarcinc 3ma cells in iris stroma which reseml bled primary melanoma of iris in fr( )zen sections (arrows).
Fig. 10. Vegetable rows) surrounded matory cells.
static
breast
the tumor
carcinoma
with
alcian
blue positivity
of
cells.
The frozen section examination may also be of some use to the anterior segment surgeon to differentiate ciliary body lesions, but tumors of this region are quite rare and it is better to rely on permanent paraffin sections for evaluation of melanoma, pseudomelanoma, medulloepithelioma and carcinoma of this region. POSTERIOR
SEGMENT
Applications of frozen section diagnosis in posterior segment surgery is limited. Occasionally it may be utilized in differential diagnosis of mass lesions if a part of the tumor is far anteriorly located. ORBIT Frozen section diagnosis has many applications in orbital surgery and it can be a valuable diagnostic
liber material (arby acute infl am-
tool for the surgeon. Many orbital surgeons, however, have been reluctant to use this technique and prefer to rely on permanent tissue specimens. This reluctance stems mainly from two sources. First, orbit surgery is not a very common procedure and because of the rarity of the frozen section request, the general pathologist, even in large centers, is not very familiar with the material. This unfamiliarity will impede reliable diagnosis. On the other hand, errors are reduced to a minimum if the orbital frozen section is done by an ocular pathologist who is familiar with the anatomy and the pathology of the territory. It is particularly helpful if the pathologist enters the operating room and functions as a part of the team during surgery. At times in situ inspection of the lesion becomes very helpful in reaching a diagnosis. There is another difficulty with frozen section diagnosis common to all surgical material. Even today
FROZEN SECTION
DIAGNOSIS
IN OPHTHALMIC
SURGERY TABLE
3
Orbital Lesion5 Xht to be Diagnosed
in Frocen Section Slides
Extensively necrotic lesions. Lesions with artefartual distortion (cauterization, crushing, etc.) L)rmphuc~tic infiltrates (lymphoma. I!-tnphoid hyperplasia, lymphocytic pseudotumor, etc.) neural tumors (SchwanSoft tissue tumors in general, oma, neurolihroma, etc.) Xfeningioma if a wage biopsy of the nerve sheath is not a\2ilahle. Lacrimal gland lesions \vith questionable mali,qnancy.
Fig.
Il. Clustrrs of retinoblastoma preparation of the optic nerve.
cells in frozen section
the technical quality of the cryosection is not equal to a paraf‘fin-embedded preparation. Particularly in the orbit where the biopsy specimen is small. the lack of definition may create major problems in di-a,qnosis. gist
Thercfbre,
should
ready
adopt
to defer
sections
arc
in orbital
surgery,
a conservative
the
obtained.
diagnosis Once
the patholo-
attitude until
this
the
and
he
permanent
understanding
is
surgeon and the pathologist, many critical decisions can he based upon the results o1‘thc frozen section in orbital surgery. In our institution, the policy is to def’er the frozen section diagnosis if‘ there is any question whatsoever, but if the histopathologic picture is clear enough to interpret thr lesion beyond any doubt, WC do not hesitate to base our course of therapy on the frozen section diagnosis. This ofcourse spares the patient a second operative procedure which would be neccssitated by abvaiting definitive histopathologic diagnosis based on permanent paraffin sections. The complications of’ thr orbital biopsy procedure are also minimized ifthe orbital mass can he removed at the time of the first orbital exploration. Thrre arc many types of orbital lesions in which thr frozen section diagnosis is extremely useful. If the cause ot‘an obscure orbital infection or abscess cm bc determined at the time of fiiozen section, the appropriate measures can he taken without delay. A good example of this is to identify fungal elements and/or ti)rciCgn bodies in ti-ozen section material Ii-om the orbit. In one such case we have identified \.cgctablc liher tnatcrial from orbital tissue samples (Fig. 10). (LSCS in Lvhich clinical suspicion is strongly in established
hetuccn
the ocular
liver of a specitic diagnosis lend themselves very well to study by frozen sections. e.g., pseudotumors, cysts, mucoceles lacrimal gland lesions, dermoid and hemangiomas. Pseudotumor cases with extcnsi\,c fibrosis and mixed inflammatory cell infiltrates arc easily diagnosed on fiiozen sections. I,ymphocytic type pseudotumors, on the other hand, can be cstrcmely diffcult to differentiate from true lymphomas e\~n on permanent sections. Today the ultimate diagnosis of’ orbital lymphoma versus Iymphoid hypcrplasia is based on immunoperoxidasc staining techniques. If this technique can be dc\,cloped to a point where it can he performed in Irss than trn minutes, it will undouhtedl), he a vcr) helpful ad,junct in diagnosis of‘orbital Iymphoid Icsions. E;\.cn if’ the exact nature of the lymphocytic infiltrate cannot he determined at the time ofti.ozen section, the identification ol‘the Iymphocytic nature 01’the lesion alone alerts thr surgeon to the fact that l‘urthrr immediate surgery is not indicated. The lipzen srction of orbital tissues in cases 01‘ mctastatic tumors can also be \aluablc to the surgeon in this rcspcct. &ain onr should remember that in cases 01 qucstionablc Frozen section diagnosis and in patic‘nts li)r whom cxtcnsi\.c surgery is planned, reliancc should always be placed on parattin cmbcdded sc‘ctions. In general, diagnosis of necrotic lesions, Iymphocytic infiltrates. unusual soli tissue tumors and questionable lacrimal gland tumors should not be attempted based on frozen section preparations (Table 3). t’urthcrmorc, the fiiozen section can be uset‘ul to idcntif‘) the unknown choroidal melanoma and retinoblastoma extending into the orbit. 12:e have had such an cxperiencr in a patient with unknown choroidal melanoma with extensive orbital invol\.cmcnt. The li-ozrn section specimen was diagnosed as a maliCgnant tumor but the diagnosis of’ melanoma could only be made at‘ter the permanent sections \vcrr a\.ailablr. Invol\.emc.nt of the optic nerve with tumor. particularl) \vith rrtinoblastoma, can easily be docu-
332
Sure Ophthalmol
l;i,9. 12. Granular tumor zen section preparation.
28(4) January-February
1984
AND
CALDWELL
calls in Ii-o-
mented quickly with a frozen section in questionable cases. In one such case, we recently found tumor at the resection margin of the optic nerve (Fig. 11). A second frozen section from the surgical margin of the nerve following additional resection was negative. Another group of cases which can be well studied by frozen section are those with extremely typical histopathologic patterns. A recent example ofthis in our experience was a granular cell tumor in the inferior orbit.” Although the type of tumor was totally unknown prior to the biopsy, the very characteristic appearance of the histology helped us to make an instant diagnosis (Fig. 12).
The authors would like to thank Paulina Hildebrand, Kirby Miller, and Sandra Bonds for their assistance in preparation of the manuscript.
References 1. Anderson RI., Crillry RI: excision and rrconstruction
A multispecialty approach to the of eyelid tumors. Tram Am Acad Ophrhalmol and Otola,:w& f?.?:I 15&l 162, 1978 2. Aurora Al.. Blodi FC: Lesions or the eyelids. A Clinicopathological Study. Sure, Ophthalmol 15:94, 1970 3. Boniuk M. Zimmerman LE: Sebaceous gland carcinoma of the cyclid, eyebrow, carunclc and orbit. Int Ophthalmol Clin 12:225-
257, 1972 Frozen section analysis 4. Bullock,Jl): thalmologs 86:534-541. 1979
of thr lacerated
globr.
Oph-
5. Drhncr LP, Rosai ,J: Frozen section examination in surgical pathology. .Wnn .2fed H/:83-92, 1977 6. Doxanas X11’, Green RM’, IlilT GE: Factors in the successful surgical management of basal cell carcinoma of the eyelids. Am, J
1981
7. I’crl-y .\I’: Granular
crll tumor (mvoblastoma) of the palpchral conjunctive causin!: psrudorpithc~iomatous hypcrplasia of thr 1981 conjunctival rpithrlium. .4m .J Ophthalmol 91:234-238, [or malignant melanoma of the iris. H. Fcrr!- Al’: Lesions mistakrn .i~rll Ophthnlmol 74:9-18. 1965 ZA. Hrmphill GL, M’ool BTU: Granular ccl1 tumor of 9. Kwcioglu the orbit. C&r report and rcvicw of the litcraturc. Ophthalmic .su,;p 14: 125- 129. 1983 ZA, Caldwcll DR. Reed 1‘H: Papillomas ollacrimal 10. Karcioglu drainagr sxstrm. A clinicopathologic r-rvirw. Ophthnl Suq (in press) Kindrrmann \TR. Shirlds ,JA, Eifcrman RA, ct al: Mctastatic renal ccl1 carcinoma to thr cyc and adnexa. Ophthalmolog, H#;l347-1350. 1981 gland carcinoma of the cyclic1 12. Lee SC:. Roth l,.\l: Scbaccous \vith pagrtoid of the bulhar and palprbral conjunctiva. J Cutan Il.
Pathol $:13&145. 13. l.ribsohn,J. prrsumcd
1977
Bullock,J. carcinoma
M’allcr R: Full thickness cyclid biopsy for in situ of thr palprbral conjunctiva.
Ophthal Sur;4 /3:840-842,
Acknowledgment
Ophthalmol 91:72&736,
KARCIOGLU
1982
Clin PLastic Surg 7:349-360. 1980 I t. Slobs FE: Chcmosurgcry. FE: Chcmosurgcry for skin cancer. Arch Dermatol112:21 l15. .\I& 215? 1976 FE: ‘I‘hc chrmosurgical method for the microscopically 16. \lohs controllrd excision of external cancer with refcrcncc to cyclid. Tlanr .4111.4cad Oph!halmol and Otolaygol 62:335-336, 1958 ‘1‘G: Modes of spread of cancer of the skin. 17. Slobs FE. Lathrop .-lrcri I>erma& $yph 66:427-439, 1952 H, Rosen P, Lane IX, Lattes R, ct al: Frozen srction 18. Nakazawa rxprriencr in 3000 casts. Am .J C/in Pathol 499:41-51, 1968 Andrew AH, et al: Role of 19. Pryman GA, Salzano ‘IC, Grecn.JL, thr CO, laser in choriorrtino-iridocyclcctomy. Ophtha/mir Surg /2:421%43 I, 198 I ofsurgical biopsy. Am J&q Pathol It36120. Rosrn G: Beginnings 363. 1977 T.4, Stegman SJ: Microscopically controlled exci21. ‘l’romovitch sion of skin tumors: Chemosurgery (Mohs): Fresh tissue tech1974 nique. Arch Dermatol 110:231-232. Reprint requests should be addressed to Zeynel A. Karcioglu, 5l.D., Dcpartmrnt of Ophthalmology, Tulanr Mrdical Center, 1430 ‘l‘ulane Avcnuc. New Orleans. Louisiana 70112.
OF OPHTHALMOLOGY
DIAGNOSTIC MORTON F. GOLDBERG,
VOLUME 28.
NUMBER 4. JANUARY-FEBRUARY
1984
AND SURGICAL
TECHNIQUES
EDITOR
Frozen Section Diagnosis in Ophthalmic ZEYNEL A. KARCIOGLU,
M.D. AND DELMAR
R. CALDWELL,
Surgery M.D.
0 ‘Brien Ocular Pathology Laboratory, Department of Ophthalmology, Tulane Medical Center, New Orleans, Louisiana
Abstract. Frozen section diagnosis can afford the opportunity for histopathological examination of excised tissues in the operating room. Because frozen section techniques have traditionally been little used in ophthalmic surgery, many pathologists are not familiar with eye tissues. However, with cooperation and understanding between the ophthalmologist and the pathologist, frozen section diagnosis may be able to identify the tissue, the pathologic process and the extent of the lesion within l&15 minutes. In this review, applications and problems of frozen section diagnosis in various types ofocular surgery are discussed. (Surv Ophthalmol28:323-332, 1984)
Key words.
frozen
section
diagnosis
l
ocular
T
pathology
l
ocular
surgery
Howard A. Kelly. “’ It was not until after 1905, when Louis B. Wilson of the Mayo Clinic published his method of staining frozen sections with methylene blue, that diagnosis during operation was accepted as a routine procedure. “’ Even after the method was widely accepted, many surgeons and pathologists were relucant to make much use of it for years. As recently as the 1950s obtaining fresh frozen section was a source of stress for surgeons and pathologists alike. The opening sentence in a paper by Malcolm Dockerty published in 1953 states that “the attitude of the busy pathologist responding to a hurried summons from the operating room for purposes of making a fresh frozen section was like his attitude toward court summons, one of distaste.“” Since then an entire generation of pathologists and surgeons have been trained in the use and interpretation of the frozen section. Many of the anxieties that plagued the pathologist when the technique was new and unfamiliar have been put aside and the frozen section is now available in most hospitals
here are few diagnostic techniques that can have such immediate and vital consequences to the patient as the frozen section diagnosis performed at the time of surgery. In order to he of use, the frozen section must be reliable and performed rapidly within 10-15 minutes. Today, the accuracy of frozen section diagnosis is reported to be 97-99 percentI and it is widely used in all surgical specialties. The use of frozen section originated in the late 19th century, following the invention of the freezing microtome. In 1891 William H. Welch examined a frozen section from a breast tumor which was being removed by W. S. Halstead. Welch’s technique was very slow and the surgeon completed the operation before the pathologist had finished the diagnostic examination. A more significant contribution was made at Johns Hopkins Hospital in 1895 when Thomas S. Cullen, a young instructor, devised a rapid method for making permanent frozen sections; this procedure became routine in the clinic of 323
324
Sure Ophthalmol
across
28(4) January-February
FALSE POSITIVE
the country.
Purpose There
and Pitfalls
is one
purpose
that is to determine the operating
room.
1) Identification gland
or lymph
of Frozen Section
in the
frozen
the surgeon’s This
section,
and
course
of action
(e.g.,
parathyroid
in
requires:
of the node?
tissue Iris
or retina?);
Identification of the pathologic process (inflammatory or neoplastic? benign or malignant?); and 3) Identification of the extent ofa lesion (surgical margin involved or free?). Certain generalizations can be made concerning the errors in frozen section diagnosis which are reduced to a minimum if all clinical information is available to the pathologist and if the frozen section technique is of high quality. Frozen section diagnosis is not a game to see whether the pathologist can make the diagnosis without any history. At times the patient may have had previous surgery and this material should be obtained and studied in advance by the pathologist. The pathologist should enter the operating room and look at the lesion in situ to make suggestions as to the way the biopsy should be taken. It is ideal to have an experienced pathologist who is conservative in attitude and, most important, who is familiar with the clinical setting to havejudgment of a given case. If the pathologic process cannot be identified, the pathologist must be honest enough to say that he/she is unable to make a diagnosis. It may be necessary to request additional tissue or defer the diagnosis until the permanent sections are prepared. But, in practically all instances a decision must be made; otherwise the pathologist’s value to the surgeon is tremendously diminished. It is essential that both the clinician and the pathologist be aware of the limitations of this diagnostic procedure. The errors of frozen section can be grouped under two main categories - false negative and false positive diagnosis. 2)
FALSE NEGATIVE
KARCIOGLU
1984
DIAGNOSIS
False negative diagnosis most often occurs if the material is not properly selected for frozen section. It may be thought that the material is representative but no significant pathologic findings are observed. Later, when all of the material is reviewed in permanent sections, an area of previously unsuspected pathology may be found. This indicates how imperative it is that the material for frozen section be selected with the greatest of care. False negative errors may also be associated with negative misinterpretation of tumor at margins of resection. As a result of this, of course, tumor tissue is left behind.
AND CALDWELL
DIAGNOSIS
False positive diagnosis occurs due to misinterpretation of the histopathologic process. The erroneous diagnosis of an inflammatory reaction as tumor infiltrate or of a benign tumor as malignant are examples of false positive errors. At times this may lead to disastrous results, e.g., removal of a healthy organ which was presumed to contain a malignant tumor. When a false positive diagnosis is made to determine the adequacy of a surgical excision the consequences are less serious, but, nevertheless, it leads to additional and unnecessary tissue removal.
Frozen Section Diagnosis Surgery
In Opthalmic
Because traditionally ophthalmic frozen section requests have been rare, pathologists in many hospitals are not familiar with eye surgery material. It may very well be a horrifying experience for a general surgical pathologist to face a 1.O X 1.O mm fragment of pupillary membrane and be asked whether this represents an epithelial downgrowth or something else. On the other hand, when the procedure is done by an ocular pathologist or by a pathologist who has interest in ophthalmic surgery, frozen section offers valuable information to the eye surgeon in many cases (Table 1). Percentage of accurate diagtiosis of ophthalmic surgery material is difficult to assess because of the small number of cases; in our experience, however, the accuracy is close to 97%.
TABLE
1
Frozen Section Diagnoses on Ophthalmic Surgery Material O’Brien Ocular Pathology Laboratory Eyelids and Conjunctiva
Basal cell carcinoma with margins Actinic keratosis Squamous papilloma Squamous cell carcinoma with margins Pterygium Conjunctival melanoma Lacrimal
Gland and Lacrimal
Inverted
(Schneiderian)
Drainage
System
papilloma
Anterior segment
Anterior segment membranes Metastatic iris tumor Primary melanoma of iris with margins Orbit
Hemangioma (capillary and cavernous) Lymphoma Ectopic lacrimal gland tissue Choroidal melanoma extension Granulomatous inflammation Squamous cell carcinoma extension Pseudotumor Granular cell tumor Retinoblastoma in optic nerve
from
FROZEN
SECTION
DIAGNOSIS
IN OPHTHALMIC
Fig. I. Simple labelling ofmargins for frozen section. With this method the margins of the excised specimen, not the margins of the remaining tissue, are examined. The deep margin can not be examined thoroughly; therefore, this technique should only be used for superficial lesions.
To obtain a maximum yield from any frozen section, certain technical points should be taken into account. Labeling of the lesion and margins should be done meticulously at the time of resection and should be simple and clearly understandable to the surgeon and pathologist. For small lesions it is best to have a simple diagram on the surgical drape and mark the margins on the diagram as the tissues are sent to the pathologist (Fig. 1). For more involved cases, it is best to work with a pathologist who can be actually present in the operating room to orient the tissues with reference to the excision site. Proper communication between the pathologist and surgeon improves the orientation and avoids frustratconversations.” ing “intercom Tissues removed for frozen section examination should be handled delicately to avoid crush arte-
325
SURGERY
facts. Care should be taken to insure that the specimens are obtained with blades and should include the full thickness of the tissue. Considering that the frozen section material in ophthalmic surgery consists of small pieces of tissue, even the slightest rough handling may result in crush artefacts which in turn produce misleading results. For example, a small cluster of crushed chronic inflammatory cells may easily be diagnosed as a focus of infiltrating tumor (Fig. 2). The frozen section specimen should not be cauterized or photocoagulated under any circumstances. Cauterized tissue is worthless for histologic interpretation. The disadvantages of tissue damage secondary to CO, laser application has been well documented by Peyman and co-workers in a recent case of uveal melanoma.“’ A point commonly overlooked by the inexperienced surgeon is that the margins of the tissue remaining around the area of tumor involvement should not be cauterized until the previously submitted tissue is proven to be free of tumor (Fig. 3). Otherwise, the adjacent layer of tissue from the questionable margin will contain severe cauterization artefacts. This becomes particularly important when one is dealing with the deep margin of the resection which is usually the subcutaneous adipose tissue. EYELIDS
AND CONJUNCTIVA
Frozen section is used to identify the nature of many eyelid lesions and also to determine the extent of disease. Although the location and other clinical features of many lesions give an idea about its nature, the ultimate diagnosis should always be based on histopathologic examination. Basal cell carcinoma accounts for approximately 90% of all malignant tumors of the eyelid.‘.” These tumors can be classified in four basic histologic
Fig. 2. A focus of inflammatory tissue with crush artefact. No cellular detail can be obtained from distorted tissue.
326
Surv Ophthalmol
28(4) January-February
1984
Fig. 3. A: Frozen section sample removed from Area B. B = Margin of remaining tissue. C = Margin of the sample corresponding to Area B. Area cauterized until Area C is proven to \\‘hen sample A is submitted for frozen of cardboard, Area C should face down tation. (For all practical purposes Area sion margin of Area B.)
B should be free of section on for proper C represents
not be tumor. a piece orienexci-
types, namely superficial, nodular, ulcerating and morphea types. The biological behavior of basal cell carcinoma is correlated with its morphologic pattern and therefore the type of the neoplasm should be determined and the treatment should be planned accordingly. For the nodular type of basal cell carcinoma, the conventional sectioning of the skin ellipse would provide a great deal of information (Fig. 4) .’ Three full-thickness sections (A, B, and C) taken from the skin ellipse would reveal satisfactory information about the surgical excision margins. This can easily be done with frozen sections. If all margins are found to be involved, additional full-thickness sections from the area of concern should be submitted for frozen section. If the deep surgical margin reveals involvement with tumor, additional specimens should be obtained from the base. At this point it is very helpful to map the base of resection and code the additional layers of tissue with letters (Fig. 5). The true edges of the resections should be marked with india ink or with different colored dyes. Thus, the areas of the residual tumor are easily marked on the map and only those areas are subsequently excised. This mapping identifies the exact location of the residual tumor and uninvolved tissue can be spared. Surgical resection is continued until there is a histologically proven tumor-free plane. The method described here is the simplest and most practical way of allowing a three-dimensional tracing of the entire tumor field which is within the means of any surgical pathology laboratory. This technique is the basis of Mohs’ chemosurgery.‘4 Mohs’ original technique utilized tissue fixation which facilitated accu-
KARCIOGLU
AND CALDWELL
rate histopathology but was caustic. The irritating nature of the zinc chloride proved to be a big disadvantage, particularly for eyelid lesions.“j To avoid the irritation, Mohs’ fresh tissue concept has been developed and proved to be the most efficacious technique for removal of skin neoplasms.‘,‘” One should realize that its accuracy depends entirely on the tissue sectioning methods, proper mapping of the surgical field and histopathologic interpretation. As was originally pointed out by Mohs and Lathrop, this histographic excision technique has proven to offer exceptional cure rates for certain types of epithelial neoplasms.‘~‘“,” In a series of 7000 basal cell carcinomas and over 2500 squamous cell carcinomas of skin treated with chemosurgery, Mohs reported 5-year survival rates of 99.3% and 94.4% respectively.‘” Mohs’ technique is not necessary in many cases of nodular basal cell carcinoma. The ulcerating, superficial and morphea types, however, are eficiently treated with this method. It is particularly useful for the medial canthus lesions and for those which are larger than 2 cm in diameter. Furthermore, the histographic excision technique produces excellent results in lesions with history of previous treatment and aggressive infiltrative character.2’ These tumors usually contain excessive amounts of fibrous tissue and extend fingerlike projections along tissue planes instead of maintaining regular growth patterns. The greatest advantage of this technique is the frozen section examination of the margins of remaining tissue rather than the margins of the excised specimen. Removal of multiple thin layers from the base of the excision, as described earlier in this review, is based upon the same principle. It is now agreed beyond any doubt that the histographic excision technique with frozen sections (Mohs or otherwise) markedly reduces recurrences and allows maximum preservation of normal tissue, as compared to any other surgical method. The limitations of this technique, however, should also be observed. When the tumor invades the orbital tissues, it becomes extremely difficult to map the areas of involvement and orient the sections for histopathologic evaluation. Consequently, the accuracy of the technique suffers considerably when one is dealing with invasive carcinoma of orbital soft tissues. It is ideal for orientation to place the full-thickness section on a piece of cardboard, the surgical excision margin facing down (Fig. 3). Furthermore, Iateral margins can be specified on the cardboard, i.e., temporal, nasal, etc. Curettage material of basal cell carcinoma is sometimes adequate for histologic study but usually is a poor specimen for frozen section diagnosis.
FROZEN SECTION DIAGNOSIS
IN OPHTHALMIC
SURGERY
327
Fig. 5. Histographic excision technique. This method offers the frozen section examination of the margins of the remaining tissue, not the margins of excised specimen. Sections a, b, c, d, e, etc. at every level (L 1,2,3, etc.) may be examined individually or may be combined to obtain larger pieces of tissue. Note that Area b at level 3 contains tumor.
Fig. 4. Conventional sectioning of a skin ellipse with nodular lesion. Sections A, B and C are sufficient to cover lateral and deep margins.
The techniques described above for diagnosing basal cell carcinoma are also quite satisfactory for other skin neoplasms of the eyelids and the periorbital region. The specimens taken from questionable squamous cell carcinomas should represent a fullthickness section of the skin to determine the depth of invasion. This is also helpful to rule out the possibility of a subepithelial lesion causing pseudocarcinomatous hyperplasia of the epithelium.’ Lesions suspected of being melanomas require meticulous techniques of biopsy. In a suspicious lesion the histologic diagnosis must be firmly established before definitive, sometimes mutilating surgery is undertaken. The biopsy should be done preferably in tolo of the grossly visible lesion with a depth extending into the subcutaneous fat. Although frozen sections can be processed at the time of surgery, it is best to base the diagnosis on permanent sections for optimal interpretation. Sebaceous gland carcinoma of the eyelid may histologically mimic many neoplastic and inflammatory lesions including squamous cell carcinoma, basal cell carcinoma, metastatic tumors, melanoma and chalazion. The difficulties in the diagnosis and
the pitfalls involved have been well documented in the literature.“.” Therefore, we are often reluctant to attempt such evaluations based on frozen section diagnosis. Sebaceous gland carcinoma with Pagetoid spread can easily be misinterpreted as squamous cell carcinoma-in-situ, as reported by Leibsohn et al.” Even in paraffin sections, this Bowenoid-like histology may be very difficult to evaluate without a full-thickness eyelid biopsy (Fig. 6). A misdiagnosis of melanoma or metastatic carcinoma may also be encountered. One of the authors (ZAK) has witnessed a case of an early sebaceous gland carcinoma which was misinterpreted as metastatic renal cell tumor in a patient who had undergone nephrectomy years earlier for renal cell carcinoma. Metastatic renal cell carcinoma, in general, can be extremely difficult to diagnose because of the unpredictable pattern of metastasis. Metastatic disease can present at any time, occasionally after decades of diagnosis of primary carcinoma, or may precede the recognition of the primary tumor.” Frozen section may be useful to diagnose a number of conjunctival lesions such as dermoid, hemangioma and lymphangioma, old organized hematoma, pinguecula and pterygium, dysplastic and neoplastic epithelial lesions and some stromal neoplasms.
328
Surv Ophthalmol
28(4) January-February
1984
KARCIOGLU
AND CALDWELL
Fig. 6. Pagetoid involvement of conjunctival epithelium by sebaceous gland carcinoma (arrows).
One technical problem related to conjunctival and cornea1 frozen section biopsies is the thinness of the tissue. This becomes particularly important when superficial premalignant lesions, such as squamous cell carcinoma in situ, or acquired precancerous melanosis is involved. At the time of frozen section the specimen should be serially sliced to examine the full thickness of the epithelium and the depth of invasion if there is any. If the adequacy of surgical margins is going to be determined it is best that the specimen is mounted on a piece of cardboard as shown in Fig. 7 for proper orientation. LACRIMAL DRAINAGE
GLAND AND LACRIMAL SYSTEM
Frozen section diagnosis can be useful in evaluating disorders of the lacrimal system. Approximately one-half of lacrimal gland tumors are epithelial in origin and the other half consists of inflammatory pseudotumors. The determination of the inflammatory versus neoplastic nature of the disease process by frozen section at the time of surgery can be extremely useful. Most commonly encountered epithelial tumors of the lacrimal gland, namely pleomorphic adenoma and adenoid cystic carcinoma, can be easily diagnosed with frozen section. Other types of adenocarcinoma, however, may be difficult to differentiate from chronic dacryoadenitis and inflammatory pseudotumors. A longstanding chronic inflammation with extensive fibrosis can alter the normal architecture of the lacrimal gland and distort the acinar pattern to mimic infiltrating adenocarcinoma. Therefore, for a questionable lacrimal gland lesion, or for a patient on whom extensive surgery is planned, it is safer to base the diagnosis
on permanent paraffin sections. Predominantly lymphocytic lesions of the lacrimal gland which are similar to lymphocytic inflammatory pseudotumor of the orbit are difficult to study with frozen sections. Therefore, it is best not to rely on frozen section diagnosis of lymphocytic lesions in the lacrimal gland region or elsewhere in the orbit. Granulomatous lesions of the lacrimal gland such as sarcoidosis, on the other hand, can easily be detected on frozen sections. Frozen sections may also be useful to identify lacrimal drainage system papillomas and carcinomas. Because of the multifocal nature of the carcinomatous changes within the papillomata of the lacrimal drainage system, one cannot rule out malignancy with one or two sections of a given tumor. Inverted (Schneiderian) papillomas of this region almost always present a certain degree of cellular atypia in certain zones of the tumor.” This atypical change may be a major pitfall at the time of frozen section examination and these areas may be over-called as carcinoma in fita. A frankly invasive squamous cell carcinoma, however, originating in this region, can easily be diagnosed with frozen section and in the majority of instances a frozen section becomes a very valuable tool to evaluate the margins of resection. Lacrimal drainage system casts which are formed by proliferation of actinomyces represent another type of pathology which can be diagnosed on frozen section. ANTERIOR
SEGMENT
Frozen section to the ophthalmic
examination also offers some help surgeon in intraocular procedures
FROZEN
SECTION
DIAGNOSIS
IN OPHTHALMIC
SURGERY
329
/rw ,, ,,j /. z
,,’
,2,h&,,
Fig. 8. Idcal
orientation
,’
,“”
of iris lesion on a piece of card-
1)oard. l:ig. 7. Ideal
orientation
of’ con,junctival
lesion
on a piece
of cardboard.
ofthe anterior
segment.
In our institution,
question-
for frozen section to distinguish epithelial downgrowth from fibrous proliferation. In one case, the section from one of these membranes was proven to contain retinal tissue. Utilization of frozen section diagnosis has also been suggested to identify retinal tissue outside of the globe in severe trauma cases.’ The membrane specimens are usually very small and at times are difficult to section in a cryo block. It may be preferable to spread these small fragments directly on a glass slide and stain them with quick stains such as methylene blue. If the specimen does not stick on the slide, a small amount of glycerin solution can he applied as a base or a granular glass slide can he used. The folded parts of the tissue are difficult to examine, therefore it is very important that these membranes are flatly spread over the glass slide. Frozen section is helpful in identifying tumor and tumor-like lesions of the iris. Although the melanotic tumors can be diagnosed in frozen section specimens in many instances, several pitfalls should be taken into consideration. In heavily pigmented tumors it may be difficult to differentiate between melanoma cells and pigment laden macrophages. Recurrent and residual iris tumors are also difficult to evaluate on frozen section material because of the presence of fibrosis and secondary inflammatory changes of initial surgery. Frozen section examination can be very useful in determining the surgical resection margin of any iris tumor. Following removal, the excised iris and tumor tissue tend to curl and become distorted. At this point it may be dificult for the pathologist to study the excision margin of the tumor. The best method of orientation is to place this specimen on a piece of cardboard with a able anterior
segment
membranes
are submitted
simple drawing indicating the clock hours (Fig. 8). In cases where the iris lesion extends toward the base of the iris, the evaluation of the excision margin becomes particularly difficult. Ideally, in difficult cases the pathologist will be present in the operating room at the time of surgery, thus enabling him to orient the specimen according to his needs. N’hen interpreting iris nodules on frozen section, one should not be influenced by the clinical diagnosis and should remember that many lesions may be mistaken clinically for melanoma of the iris.” In Ferry’s clinicopathologic study of 69 eyes enucleated with clinical diagnosis of melanoma of the iris, no tumor was present in 24 eyes (35%). His study was done in 1965 and included old material from AFIP tiles, but even today one should always remember that a number of iris lesions may mimic melanoma clinically and histologically {Table 2). ,4n example of this problem is depicted in Fig. 9 which was obtained from an iris nodule. A definitive differential between melanoma and metastatic tumor could not be made on frozen sections. Only after permanent preparations with special stains were available did it become clear that the lesion represented a meta-
TABLE Lh@rential
Diagnosis
Clinical :\nterior staphyloma Inflammatory mass (pseuin anterior dotumor) chamber Juvenile xanthogranuloma Cysts in anterior chamber Stromal atrophy of the iris Postoperative scar of iris Foreign body in iris Hematoma in iris Nexus and melanocytoma Metastatic tumor
2 oy Iris .2lelanoma
Histopathologic News Melanocytoma Inflammatory pigment
nodule with laden macro-
phages Hematoma with laden macrophages Metastatic tumor
pigment
Surv Ophthalmol
28(4) January-February
1984
KARCIOGLU
AND
CALDWELL
r;is. 9. Clusters of adenocarcinc 3ma cells in iris stroma which reseml bled primary melanoma of iris in fr( )zen sections (arrows).
Fig. 10. Vegetable rows) surrounded matory cells.
static
breast
the tumor
carcinoma
with
alcian
blue positivity
of
cells.
The frozen section examination may also be of some use to the anterior segment surgeon to differentiate ciliary body lesions, but tumors of this region are quite rare and it is better to rely on permanent paraffin sections for evaluation of melanoma, pseudomelanoma, medulloepithelioma and carcinoma of this region. POSTERIOR
SEGMENT
Applications of frozen section diagnosis in posterior segment surgery is limited. Occasionally it may be utilized in differential diagnosis of mass lesions if a part of the tumor is far anteriorly located. ORBIT Frozen section diagnosis has many applications in orbital surgery and it can be a valuable diagnostic
liber material (arby acute infl am-
tool for the surgeon. Many orbital surgeons, however, have been reluctant to use this technique and prefer to rely on permanent tissue specimens. This reluctance stems mainly from two sources. First, orbit surgery is not a very common procedure and because of the rarity of the frozen section request, the general pathologist, even in large centers, is not very familiar with the material. This unfamiliarity will impede reliable diagnosis. On the other hand, errors are reduced to a minimum if the orbital frozen section is done by an ocular pathologist who is familiar with the anatomy and the pathology of the territory. It is particularly helpful if the pathologist enters the operating room and functions as a part of the team during surgery. At times in situ inspection of the lesion becomes very helpful in reaching a diagnosis. There is another difficulty with frozen section diagnosis common to all surgical material. Even today
FROZEN SECTION
DIAGNOSIS
IN OPHTHALMIC
SURGERY TABLE
3
Orbital Lesion5 Xht to be Diagnosed
in Frocen Section Slides
Extensively necrotic lesions. Lesions with artefartual distortion (cauterization, crushing, etc.) L)rmphuc~tic infiltrates (lymphoma. I!-tnphoid hyperplasia, lymphocytic pseudotumor, etc.) neural tumors (SchwanSoft tissue tumors in general, oma, neurolihroma, etc.) Xfeningioma if a wage biopsy of the nerve sheath is not a\2ilahle. Lacrimal gland lesions \vith questionable mali,qnancy.
Fig.
Il. Clustrrs of retinoblastoma preparation of the optic nerve.
cells in frozen section
the technical quality of the cryosection is not equal to a paraf‘fin-embedded preparation. Particularly in the orbit where the biopsy specimen is small. the lack of definition may create major problems in di-a,qnosis. gist
Thercfbre,
should
ready
adopt
to defer
sections
arc
in orbital
surgery,
a conservative
the
obtained.
diagnosis Once
the patholo-
attitude until
this
the
and
he
permanent
understanding
is
surgeon and the pathologist, many critical decisions can he based upon the results o1‘thc frozen section in orbital surgery. In our institution, the policy is to def’er the frozen section diagnosis if‘ there is any question whatsoever, but if the histopathologic picture is clear enough to interpret thr lesion beyond any doubt, WC do not hesitate to base our course of therapy on the frozen section diagnosis. This ofcourse spares the patient a second operative procedure which would be neccssitated by abvaiting definitive histopathologic diagnosis based on permanent paraffin sections. The complications of’ thr orbital biopsy procedure are also minimized ifthe orbital mass can he removed at the time of the first orbital exploration. Thrre arc many types of orbital lesions in which thr frozen section diagnosis is extremely useful. If the cause ot‘an obscure orbital infection or abscess cm bc determined at the time of fiiozen section, the appropriate measures can he taken without delay. A good example of this is to identify fungal elements and/or ti)rciCgn bodies in ti-ozen section material Ii-om the orbit. In one such case we have identified \.cgctablc liher tnatcrial from orbital tissue samples (Fig. 10). (LSCS in Lvhich clinical suspicion is strongly in established
hetuccn
the ocular
liver of a specitic diagnosis lend themselves very well to study by frozen sections. e.g., pseudotumors, cysts, mucoceles lacrimal gland lesions, dermoid and hemangiomas. Pseudotumor cases with extcnsi\,c fibrosis and mixed inflammatory cell infiltrates arc easily diagnosed on fiiozen sections. I,ymphocytic type pseudotumors, on the other hand, can be cstrcmely diffcult to differentiate from true lymphomas e\~n on permanent sections. Today the ultimate diagnosis of’ orbital lymphoma versus Iymphoid hypcrplasia is based on immunoperoxidasc staining techniques. If this technique can be dc\,cloped to a point where it can he performed in Irss than trn minutes, it will undouhtedl), he a vcr) helpful ad,junct in diagnosis of‘orbital Iymphoid Icsions. E;\.cn if’ the exact nature of the lymphocytic infiltrate cannot he determined at the time ofti.ozen section, the identification ol‘the Iymphocytic nature 01’the lesion alone alerts thr surgeon to the fact that l‘urthrr immediate surgery is not indicated. The lipzen srction of orbital tissues in cases 01‘ mctastatic tumors can also be \aluablc to the surgeon in this rcspcct. &ain onr should remember that in cases 01 qucstionablc Frozen section diagnosis and in patic‘nts li)r whom cxtcnsi\.c surgery is planned, reliancc should always be placed on parattin cmbcdded sc‘ctions. In general, diagnosis of necrotic lesions, Iymphocytic infiltrates. unusual soli tissue tumors and questionable lacrimal gland tumors should not be attempted based on frozen section preparations (Table 3). t’urthcrmorc, the fiiozen section can be uset‘ul to idcntif‘) the unknown choroidal melanoma and retinoblastoma extending into the orbit. 12:e have had such an cxperiencr in a patient with unknown choroidal melanoma with extensive orbital invol\.cmcnt. The li-ozrn section specimen was diagnosed as a maliCgnant tumor but the diagnosis of’ melanoma could only be made at‘ter the permanent sections \vcrr a\.ailablr. Invol\.emc.nt of the optic nerve with tumor. particularl) \vith rrtinoblastoma, can easily be docu-
332
Sure Ophthalmol
l;i,9. 12. Granular tumor zen section preparation.
28(4) January-February
1984
AND
CALDWELL
calls in Ii-o-
mented quickly with a frozen section in questionable cases. In one such case, we recently found tumor at the resection margin of the optic nerve (Fig. 11). A second frozen section from the surgical margin of the nerve following additional resection was negative. Another group of cases which can be well studied by frozen section are those with extremely typical histopathologic patterns. A recent example ofthis in our experience was a granular cell tumor in the inferior orbit.” Although the type of tumor was totally unknown prior to the biopsy, the very characteristic appearance of the histology helped us to make an instant diagnosis (Fig. 12).
The authors would like to thank Paulina Hildebrand, Kirby Miller, and Sandra Bonds for their assistance in preparation of the manuscript.
References 1. Anderson RI., Crillry RI: excision and rrconstruction
A multispecialty approach to the of eyelid tumors. Tram Am Acad Ophrhalmol and Otola,:w& f?.?:I 15&l 162, 1978 2. Aurora Al.. Blodi FC: Lesions or the eyelids. A Clinicopathological Study. Sure, Ophthalmol 15:94, 1970 3. Boniuk M. Zimmerman LE: Sebaceous gland carcinoma of the cyclid, eyebrow, carunclc and orbit. Int Ophthalmol Clin 12:225-
257, 1972 Frozen section analysis 4. Bullock,Jl): thalmologs 86:534-541. 1979
of thr lacerated
globr.
Oph-
5. Drhncr LP, Rosai ,J: Frozen section examination in surgical pathology. .Wnn .2fed H/:83-92, 1977 6. Doxanas X11’, Green RM’, IlilT GE: Factors in the successful surgical management of basal cell carcinoma of the eyelids. Am, J
1981
7. I’crl-y .\I’: Granular
crll tumor (mvoblastoma) of the palpchral conjunctive causin!: psrudorpithc~iomatous hypcrplasia of thr 1981 conjunctival rpithrlium. .4m .J Ophthalmol 91:234-238, [or malignant melanoma of the iris. H. Fcrr!- Al’: Lesions mistakrn .i~rll Ophthnlmol 74:9-18. 1965 ZA. Hrmphill GL, M’ool BTU: Granular ccl1 tumor of 9. Kwcioglu the orbit. C&r report and rcvicw of the litcraturc. Ophthalmic .su,;p 14: 125- 129. 1983 ZA, Caldwcll DR. Reed 1‘H: Papillomas ollacrimal 10. Karcioglu drainagr sxstrm. A clinicopathologic r-rvirw. Ophthnl Suq (in press) Kindrrmann \TR. Shirlds ,JA, Eifcrman RA, ct al: Mctastatic renal ccl1 carcinoma to thr cyc and adnexa. Ophthalmolog, H#;l347-1350. 1981 gland carcinoma of the cyclic1 12. Lee SC:. Roth l,.\l: Scbaccous \vith pagrtoid of the bulhar and palprbral conjunctiva. J Cutan Il.
Pathol $:13&145. 13. l.ribsohn,J. prrsumcd
1977
Bullock,J. carcinoma
M’allcr R: Full thickness cyclid biopsy for in situ of thr palprbral conjunctiva.
Ophthal Sur;4 /3:840-842,
Acknowledgment
Ophthalmol 91:72&736,
KARCIOGLU
1982
Clin PLastic Surg 7:349-360. 1980 I t. Slobs FE: Chcmosurgcry. FE: Chcmosurgcry for skin cancer. Arch Dermatol112:21 l15. .\I& 215? 1976 FE: ‘I‘hc chrmosurgical method for the microscopically 16. \lohs controllrd excision of external cancer with refcrcncc to cyclid. Tlanr .4111.4cad Oph!halmol and Otolaygol 62:335-336, 1958 ‘1‘G: Modes of spread of cancer of the skin. 17. Slobs FE. Lathrop .-lrcri I>erma& $yph 66:427-439, 1952 H, Rosen P, Lane IX, Lattes R, ct al: Frozen srction 18. Nakazawa rxprriencr in 3000 casts. Am .J C/in Pathol 499:41-51, 1968 Andrew AH, et al: Role of 19. Pryman GA, Salzano ‘IC, Grecn.JL, thr CO, laser in choriorrtino-iridocyclcctomy. Ophtha/mir Surg /2:421%43 I, 198 I ofsurgical biopsy. Am J&q Pathol It36120. Rosrn G: Beginnings 363. 1977 T.4, Stegman SJ: Microscopically controlled exci21. ‘l’romovitch sion of skin tumors: Chemosurgery (Mohs): Fresh tissue tech1974 nique. Arch Dermatol 110:231-232. Reprint requests should be addressed to Zeynel A. Karcioglu, 5l.D., Dcpartmrnt of Ophthalmology, Tulanr Mrdical Center, 1430 ‘l‘ulane Avcnuc. New Orleans. Louisiana 70112.