How to Not Freeze on a Frozen 

When transitioning from trainee to attending, fear can arise in various aspects, potentially including a new place to call home, a new workplace, new colleagues, and new responsibilities. Frozen section analysis is likely one of the biggest fears that New-in-Practice pathologists would attest to when starting their new role. Essentially, it is now your responsibility to make those fast-paced, difficult decisions that dictate patient care. Though confidence comes with experience, knowing the following tips can hopefully help ease the stress and fear of this vital, yet complex, procedure. 

Do not rush

Time constraints are a reality and a crutch of frozen section analysis. Only a short amount of time, approximately 20 minutes, is allotted from the arrival of the specimen in the gross room to relaying the diagnosis to the operating room. These twenty minutes do not generally consider outside factors such as the distance the pathologist has to travel to the gross room once paged, if there is support staff and their level of experience, the number of specimens coming in to be frozen at one time, the complexity of the specimen, or technical issues that may arise. All in all, frozen sections have many variables. Therefore, it is important to focus on the aspects that you can control and take your time. Rushing can lead to various mistakes such as cutting yourself, inadequate freezing and/or staining, and missing a crucial area on the slide. All these errors help no one. It is better to go at an appropriate pace for you to arrive at the correct diagnosis.  

Know the history of the patient and the question being asked by the surgeon

Never go into a frozen section blindly. You should always look up a patient’s history to know why surgeons are sending the frozen and what questions they want answered. This information can help in the selection of tissue sections to be frozen or in deciding if special studies, such as lymphoma work-up, are needed. If the notes in the medical chart are vague and do not shed light on why the frozen is being sent, do not be afraid to ask the surgeon, “How will my diagnosis change the surgical management?” Finally, if the patient has a rare prior diagnosis and the previous case is available, reviewing those slides can alert you to the morphologic features to look for within the frozen section slides.  

Know the limitations and pitfalls of a frozen section

Putting too much pressure on yourself to arrive at the exact diagnosis can be quite stressful. Know what parameters are important and how they will alter surgical management. Often, surgeons only need to know if a lesion is benign or malignant to proceed with staging or to end the surgery. Answers about tumor type or if the tumor is primary or metastatic are often not needed at that point in time. Moreover, frozen section artifacts can alter morphology and therefore lead to an incorrect diagnosis. If a surgeon is insistent on having you land on a particular answer to one of these questions, you can choose to favor one diagnosis over another, so long as it is prefaced that the diagnosis could change once the permanent sections are reviewed.

Troubleshoot before exhausting the tissue

A technical issue can arise while trying to cut a frozen section. Some may be out of your control, such as a cryostat taking an abnormally long time to freeze, or being excessively cold, or a turn wheel being faulty, causing the blade to jump. However, some issues can be fixed. For example, always make sure a blade is in the cryostat. We always assume one is present, but if the tissue is not cutting correctly, a missing blade could be the culprit. If a blade is present and the tissue is not cutting properly, you can change the blade; perhaps it was dulled by too many sections being cut or by a biopsy clip mistakenly being left in the tissue. If the tissue embedded in the Optimal Cutting Temperature (OCT) medium gets knocked off the chuck, you can melt it down and start on a new chuck. Troubleshooting can take time but, in the end, it can save the tissue from being exhausted, leaving you without a diagnosis to relay to the surgeon.  

Don’t be afraid to ask for help from your colleagues

If you are unsure of the diagnosis, always try to reach out to someone for help. Your diagnosis will change the patient’s management and so another set of eyes can always help, especially when you are New-in-Practice. You should never feel embarrassed about asking for help; it shows great maturity to place the patient’s needs before your own ego.

If help is not available and you cannot arrive at a diagnosis, be conservative

If you are unsure about the diagnosis and help from a colleague is not readily available, be conservative or opt to defer the diagnosis to the permanent section. Though not ideal, it is preferable for the patient to have to return for a second procedure to receive proper staging than for unnecessary procedures to take place that cannot be reversed.

In summary, frozen section analysis is a high-stakes and high-stress situation that exists in pathology. This is even more heightened at the beginning of your career. However, remembering to adequately prepare for your time on service, know the limitations of the procedure, take your time, troubleshoot when needed, and not be afraid to ask for help is essential. Following these tips, along with the experience that comes with time, will prevent you from “freezing” and deliver optimal patient care. 

Carissa LaBoy, MD, FCAP, is an assistant professor of pathology with a subspecialty in breast pathology at Northwestern University Feinberg School of Medicine. Dr. LaBoy completed her residency training at McGaw Medical Center of Northwestern University and is board certified in anatomic and clinical pathology.