Frozen section of skin specimens

Recommendations of the International Society of Geriatric Oncology on skin cancer management in older patients

INTRODUCTION

Non-melanoma skin cancer (NMSC) is becoming ever more prevalent among older adults. However, older adults with NMSC are often underrepresented in clinical trials and guidelines on effective management is still unclear. The International Society of Geriatric Oncology (SIOG) created a multi-disciplinary task force to explore the potential in developing practical guidelines for the treatment of older patients with basal cell carcinoma (BCC) and skin (cutaneous) squamous cell carcinoma (cSCC).

MATERIALS AND METHODS

A systematic literature search to identify relevant and up-to-date literature on treatment of NMSC in older adults was conducted on various databases including MEDLINE, Embase, CINAHL, Cochrane, and PubMed. The resulting papers were discussed by an expert panel, leading to a consensus recommendation.

RESULTS

A total of 154 articles were identified for the expert panel to utilise in generating consensus recommendations. A major focus on geriatric assessment and management options including surgery, radiotherapy, systemic therapy, clinical monitoring, and medical/medicophysical therapy were reviewed for recommendations.

DISCUSSION

Patient age should not be the sole deciding factor in the management of patients with NMSC. Assessment from a multidisciplinary team (MDT) is crucial, and the decision-making process should consider the patient's lifestyle, needs, and expectations. A comprehensive geriatric assessment should also be considered. Patients should feel empowered to advocate for themselves and have their views considered a part of the MDT discussion.

Intraoperative assessment of surgical margins using "en face" frozen sections in the management of cutaneous carcinomas

Background

Basal cell and squamous cell carcinomas (BCC and SCC) are the most common types of cancer worldwide. Intraoperative assessment of surgical margins by frozen section has been widely used to ensure disease-free margins. The intraoperative “en face” freezing technique evaluates all peripheral and deep margins.

Objective

To report the results of the “en face” freezing technique in relation to tumor recurrence and agreement with paraffin-embedded tissue examination.

Methods

Retrospective analysis of patients undergoing surgical excision of BCC and SCC at the A. C. Camargo Cancer Center, Brazil.

Results

This study included 542 skin carcinomas, which were excised from 397 patients. A total of 201 male patients (50.6%), and 196 female patients (49.4%) were assessed, whose mean age was 64 years. The tumors were mostly located on the head and neck region (87.8%). BCC corresponded to 79.7% of the cases. The mean follow-up was 38 months. Tumor relapse occurred in 0.86% of the primary tumors and 3.7% of recurrent tumors. The result of the intraoperative “en face” frozen section evaluation was in agreement with the final result of the anatomopathological examination (paraffin test) in 98% of the lesions.

Study limitations

Not having a minimum follow-up time of 5 years for all patients.

Conclusion

The “en face” freezing technique shows low tumor relapse, being reliable and safe to guarantee negative surgical margins of the tumor.

Reconstructive Techniques in Melanoma for the Surgical Oncologist

Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.

Cutaneous soft tissue sarcomas: survival-related factors

Cutaneous sarcomas are a heterogeneous group of rare mesenchymal neoplasms representing less than 1% of malignant tumors. Histology report remains the cornerstone for the diagnosis of these tumors. The most important clinicopathologic parameters related to prognosis include larger tumor size, high mitotic index, head and neck location, p53 mutations, depth of infiltration and histological grade, vascular and perineural invasion as well as the surgical margins status. Applying advanced biopsy techniques might offer more precise assessment of surgical margins, which constitutes a significant precondition for the management of these tumors. The management of cutaneous soft tissue sarcomas requires a multidisciplinary approach. Surgery remains the standard treatment, nonetheless adjuvant therapy may be required, consisting of radiotherapy, chemotherapy, and molecular targeted therapies to improve treatment outcomes. The role of molecular profiling in the treatment of uncontrolled disease is promising, but it may be offered to a relatively small proportion of patients and its use is still considered experimental in this setting. Due to the rarity of the disease, there is a need for knowledge and experience to be shared, pooled, organized and rationalized so that recent developments in medical science can have a major impact on the disease course. Multicenter clinical trials are needed to improve the care of patients with cutaneous sarcomas.

Validation of a new technique to freezing and embedding tissue in Mohs surgery, using an animal model

PURPOSE

To validate the innovative Dry Ice method, comparing it with two standard methods currently used for tissue processing in Mohs surgery, the Heat Sink method and the Miami Special.

METHODS

Forty eight samples of pigs kin with the standard beveled Mohs technique were used, and randomly allocated into six groups. Each group was processed with one of the 3 methods and evaluated for: The freezing time, the depth required to cut into the block to obtain a complete section, and the quality of histological slides analyzed with a image software. The statistical analysis was performed with the software SAS(r) System. The inferential analysis was made by one-way ANOVA.

RESULTS

The Miami Special showed a processing time significantly shorter than Dry Ice method and Heat Sink method. There was no significant difference in the depth required to cut into the blocks, and area of surgical margins visualized.

CONCLUSION

The Dry Ice method was as efficient as the other two methods currently used in Mohs surgery, considering the individual advantages and disadvantages of each method.

Histopathologic pitfalls of Mohs micrographic surgery and a review of tumor histology

Mohs micrographic surgery is a specialized subset of staged surgical excisions with each subsequent stage being driven largely by the histologic findings of the previous stage. Therefore, it is imperative that histologic analysis is performed in an accurate manner. Frozen section and tissue flattening is a crucial step in Mohs surgery. Frozen sections introduce certain artifacts and these artifacts must be interpreted in the correct context. Basal and squamous cell carcinomas are the most common tumors encountered in Mohs micrographic surgery, and their histopathology is also associated with certain "pitfalls". Basal cell carcinoma should be distinguished from hair follicles, folliculocentric basaloid proliferations, poromas, nevus sebaceous, desmoplastic trichoepitheliomas, and spiradenomas, to name but a few histologic entities. Similarly, squamous cell carcinoma should be distinguished from hypertrophic actinic keratoses, pseudoepitheliomatous hyperplasia, sebaceous carcinoma, and microcystic adnexal carcinoma. In addition, there are numerous subtypes of basal cell and squamous carcinomas that the Mohs surgeon should be aware of due to differences in the biologic behavior of these tumors. This review presents a number of the common histologic pitfalls of Mohs micrographic surgery and a review of tumor histology.

Safety and efficacy of the keystone and rhomboid flaps for immediate reconstruction after wide local excision of non-head and neck melanomas

Background

After wide local excision of cutaneous melanoma, large defects not amenable to simple primary closure are often covered with skin grafts. We report our experience using the rhomboid and keystone flaps to immediately close large axial and extremity wounds after potentially curative surgery for non-head and neck melanomas.

Methods

Between January 2011 and September 2016, demographic, operative, pathologic, and outcome data were prospectively collected on 60 patients who underwent wide local excision of melanoma followed by immediate flap reconstruction. Flaps were of either rhomboid or keystone type. Chi-square analysis was used to compare relationships between factors.

Results

All procedures were done by the senior author and as outpatient surgery. No patient required a surgical drain unless they were undergoing concomitant radical regional node dissection. Flap separation (arbitrarily defined as a >5-mm dehiscence of the suture line) occurred in 16/61 patients (26 %). No patient had flap loss. The risk of flap morbidity was significantly higher if the primary tumor was on the distal extremity—10 of 24 patients (42 %), all with keystone flaps—than if it was on the trunk or the proximal extremity (6/37 patients, 16 %), p = 0.04. There were no margins positive for either invasive or in situ melanoma in the entire cohort.

Conclusions

Simple transposition flaps can successfully cover large defects after melanoma excision without the need for skin grafting. Keystone flaps in the distal extremity are more prone to separation, but this is minor and does not result in flap loss. There is minimal risk of a positive margin requiring flap takedown and a second re-excision.

Frozen section diagnosis for non-melanoma skin cancers: correlation with permanent section diagnosis

Frozen section pathology is routinely used for margin assessment of non-melanoma skin cancer (NMSC). Frozen section can also be used for the primary diagnosis of several skin lesions. Limited data exist on the accuracy of frozen section in the diagnosis of NMSC. We performed a retrospective chart review of 300 cases in which frozen section diagnoses were compared with permanent section diagnoses of NMSC. Frozen section and permanent section pathology were concordant 83.3% of the time, with the highest concordance rates noted for basal cell carcinoma (145/153, 95%). Our results show a high level of concordance between frozen section and corresponding permanent section pathology diagnosis for NMSC. The rapidity of frozen section tissue processing and pathology reporting makes this technique useful in dermatologic practice for immediate diagnosis and management of NMSC. Further studies should explore strategies to decrease or eliminate discrepancies between frozen and permanent section diagnosis.

The use of frozen section in the excision of cutaneous malignancy: a Queensland experience

Frozen section is known to be a valuable tool in the setting of indistinct lesions, lesions in cosmetically or functionally important areas, and those with recurrent or residual tumors. Most non-Mohs surgery studies comparing frozen section with paraffin sections suggest a concordance rate of 85% to 90%, whereas studies with Mohs surgery often suggest concordance rates of 95% to 98%. We do not perform Mohs surgery at our institutions but feel that the accuracy of frozen section is relatively high. Frozen-section data from between 2005 and 2011 was analyzed, and a total of 150 cases was found and assessed. Most of the cases were basal cell carcinomas and squamous cell carcinomas, with most arising in the head and neck region. Half of the resections were for previous incomplete margins with the other half being primary excisions. The frozen section was accurate in 97.7% of the cases when compared with the formal paraffin sections. However, the incomplete rate was higher at 14.8% because of patients with known positive margins on frozen section and the use of less accurate techniques of specimen analysis. We feel that, when used appropriately, frozen section can be a reliable tool and that a negative result should provide the surgeon enough reassurance as to undertake immediate reconstruction.

Nonmelanoma skin cancer of the head and neck: surgical treatment

This article focuses on the surgical treatment of nonmelanoma skin cancers of the head and neck. The risk factors of nonmelanoma skin cancers for recurrence and metastases that are important for choosing the best treatment option are summarized. Surgical treatment options including surgical excision with standard margins, frozen section, staged surgery, and Mohs micrographic surgery are described. Indications, techniques, outcomes, and advantages and disadvantages of each approach are reviewed. Finally, management of incomplete excisions is discussed.

Oncologic clearance with preservation of reconstructive options: literature review and the 'delayed reconstruction after pathology evaluation (DRAPE)' technique

Intraoperative frozen section and Mohs' micrographic surgery (MMS) are two techniques used to ensure oncological clearance without resorting to unnecessarily wide margins that might compromise reconstructive options for definitive wound closure. In addition to some technical issues, these techniques are suboptimal for resection of tumours such as melanoma, where specific tissue margins at histopathology are required to ensure minimal risk of local recurrence. We describe a technique that minimizes the amount of tissue excised and uses definitive paraffin sections interpreted in a pathology laboratory in order to delay reconstruction until after clear oncologic margins are obtained. This 'delayed reconstruction after pathology evaluation (DRAPE)' technique is particularly directed at extensive and complicated skin lesions, located in areas of the body that can be difficult to reconstruct and are prone to disfigurement and/or loss of function. A review of the literature is undertaken, establishing the role of each technique in achieving clear surgical margins. A case example is presented, highlighting the role of the DRAPE approach. The DRAPE technique is presented as a useful option for high-risk lesions, especially within aesthetically sensitive regions or for complex reconstructions, and when reconstruction can be reasonably delayed while tumour clearance is established.

Mohs frozen tissue sections in comparison to similar paraffin-embedded tissue sections in identifying perineural tumor invasion in cutaneous squamous cell carcinoma

BACKGROUND

Perineural invasion (PNInv) in cutaneous squamous cell carcinoma (cSCC) increases the risk of recurrence, possibly because of suboptimal identification on frozen or paraffin-embedded tissue sections. Perineural inflammation (PNInf) may portend PNInv.

OBJECTIVE

We sought to correlate identification of PNInv and PNInf in hematoxylin-eosin-stained Mohs frozen sections with PNInv and PNInf identified in similarly oriented paraffin-embedded sections obtained in cases of cSCC.

METHODS

We reviewed same patient Mohs frozen and paraffin-embedded tissue sections for all patients presenting within a 2-year period to our Mohs micrographic surgical unit for removal of cSCC with PNInv or PNInf identified on either type of tissue section.

RESULTS

Of 537 patients undergoing surgical resection of cSCC, 21 (3.9%) had either PNInv (n = 11) or PNInf (n = 10) on frozen sections. PNInv on Mohs frozen sections was identified in 11 cases and confirmed on paraffin-embedded sections in 9 cases (82%). Paraffin-embedded sections failed to identify PNInv present in Mohs frozen sections in two (2/11), or 18% of cases. PNInf on Mohs frozen sections was confirmed on paraffin-embedded sections in 3 cases (30%), but PNInv was identified in 5 cases (50%).

LIMITATIONS

Our results are a retrospective case review from a specific time period by one institution. Furthermore, it is impossible to compare identical tissue specimens using two sequential tissue processing techniques.

CONCLUSION

PNInv can be accurately identified with Mohs frozen sections. PNInf on Mohs frozen sections suggests the presence of PNInv and requires further histologic investigation.

Diagnostic accuracy of frozen section tests for surgical diseases

OBJECTIVE

To evaluate the accuracy of frozen section tests at different anatomical sites performed in an academic department of pathology.

METHODS

We conducted a retrospective study from a computerized database of all frozen section tests. These diagnoses were compared to definite paraffin, used as controls. The tests were divided into three groups: inconclusive, consistent and inconsistent, the latter being subdivided into false positives and false negatives. The main indications for examinations and anatomical sites involved with diagnostic disagreements were also analyzed.

RESULTS

Four hundred and thirty-three specimens were frozen tested, and the main indication was diagnostic (75.75%). In 404 tests (93.30%) diagnoses of biopsies in paraffin and frozen section were consistent. In 20 cases (4.62%) the results of frozen section biopsy were inconclusive and in 9 (2.08%) they were false negative. There were no false positive results. The most commonly assessed organ was the thyroid (25.64%). In the overall analysis, the body region most related with inconclusive diagnoses was the thyroid (seven cases) and in relation to specific sites it was the lungs/pleura/mediastinum (13.33%). Skin was the organ that showed more discordant diagnoses between frozen biopsies and paraffin.

CONCLUSION

The global accuracy of frozen section was 93.30%; for specific anatomical sites, diagnostic accuracy ranged from 86.67% to 100%.

Can we put a simplified algorithm for reconstruction of large scalp defects following tumor resection?

Background

Reconstruction of large scalp defects after tumor resection is a challenging problem. We aimed at putting an algorithm for reconstruction of those defects.

Methods

Forty-two patients with scalp malignancies were enrolled in this study. Tumors were resected to a 1 cm negative margin and defects were reconstructed according to their size and to patient general condition.

Results

No peri-operative mortality was encountered. Usage of free flaps was superior in cosmoses and function with an acceptable rate of complications.

Conclusion

for scalp defects wider than100 cm², the best tool of reconstruction is free flaps. Pedicled distant flaps are reserved if free flaps are not feasible or failed. Split thickness skin grafts are cosmetically inferior and not suitable for recurrent and irradiated tumours and better reserved for patients who cannot tolerate major operations.

Histologic pitfalls in the Mohs technique

The success of the Mohs procedure depends on the reliability of each step in the technique. Pitfalls in histologic preparation of the tissue specimens may occur during debulking, excising, orienting, creating the map, sectioning, inking, tissue flattening and freezing, cutting, slide fixation, staining, and mapping the tumor. Challenges are also present in interpreting the slides. Diagnostic pitfalls include floaters, inflammatory conditions resembling tumor, and perineural invasion. The technique requires time, teaching, and a sufficient quantity of cases from which to learn, as well as attention to the pitfalls that occur while processing tissue specimens and interpreting and mapping the histology.

Multidisciplinary approach to large cutaneous tumors of the head and neck

Large cutaneous tumors of the head and neck provide challenges for complete excision and optimal reconstruction. Collaborative intraoperative Mohs micrographic surgery offers efficient and reliable extirpation of large cutaneous malignancies of the head and neck and immediate reconstruction of resultant defects.

A useful alternative approach for the treatment of well-demarcated Basal cell carcinoma: surgical excision and margin control with tzanck smear test

OBJECTIVE

To analyze the accuracy of the Tzanck smear test (TST) for margin control in surgery for well-demarcated basal cell carcinoma (BCC).

METHODS AND MATERIALS

Twenty-one patients with well-demarcated BCC were included in this study. After local anesthesia, the tumors were excised. The pathologist examined the frozen sections. If the tumor cells were observed in the margin, a re-excision was done. This procedure was repeated until the margin was tumor free. After each excision, Tzanck smear samples were taken from the defect area. The samples obtained were stained with May-Grünwald-Giemsa and examined. The accuracy of TST was then analyzed by comparison of the TST results with those of frozen section examination.

RESULTS

The sensitivity and specificity of TST for margin assessment were 1.00 (95% confidence interval (CI)=1.00-1.00) and 0.99 (95% CI=0.98-1.00), respectively. Positive and negative predictive values and the diagnostic accuracy for TST were 0.94 (95% CI=0.84-1.05), 1.00 (95% CI=1.00-1.00), and 1.00 (95% CI=0.99-1.00), respectively. No recurrences were observed in the average 2-year follow-up period.

CONCLUSION

The high accuracy of TST for margin control is encouraging to develop a practical alternative approach for the treatment of well-demarcated BCC.

The universal detection of antigens from one skin biopsy specimen

BACKGROUND

Immunohistochemistry is an important tool in dermatology but is limited. Certain antigens can only be preserved in formalin-fixed paraffin-embedded sections, while others can only be detected on frozen sections, resulting in situations where two biopsies are needed. We aimed to develop a technique for universal detection of different antigens out of just one biopsy specimen.

METHODS

Single biopsies were obtained from lesional skin of patients with psoriasis. Standard sample procedures for frozen and paraffin-embedded sections were used. To convert frozen tissue into paraffin-embedded sections, the biopsy specimen was disposed of the embedding medium and subsequently fixed in 10% neutral buffered formalin. We applied various antigen retrieval techniques with alkaline solutions. The differential expression of keratin 10, keratin 15, CD3, CD26 and human beta defensin-2 (HBD-2) was examined using immunohistochemical staining.

RESULTS

We showed that keratin 10 and 15 can be stained on both frozen and paraffin-embedded sections. Staining of paraffin-embedded sections required unmasking with trypsin and Tris-buffered saline Tween solution, respectively. CD3 and CD26 can only be detected on frozen sections, while HBD-2 can only be detected on paraffin-embedded sections.

CONCLUSION

We have described a straightforward technique that gives us the opportunity to use just one biopsy specimen to obtain frozen sections as well as paraffin-embedded sections.

Treatment of dermatofibroma sarcoma protuberans using modified Mohs micrographic surgery: no recurrences and smaller defects

OBJECTIVES

The purpose of this study was to evaluate the use of modified Mohs micrographic surgery (MMS) for dermatofibroma sarcoma protuberans (DFSP) in a single institution by a single surgeon.

METHODS

The authors conducted a retrospective analysis of 25 patients with DFSP who were treated with modified MMS over the past 19 years at Scripps Clinic.

RESULTS

Of the 25 patients treated with modified MMS for DFSP, there were no identifiable recurrences. The mean follow-up time was 101 months. The defect sizes of DFSP lesions treated by modified MMS are smaller than if the lesions had been treated with the standard wide local excision (WLE) margins of 3 cm.

LIMITATIONS

This is a retrospective analysis using the data of one surgeon. Five of the 25 patients were not examined in our office. Not all patients had 5-year follow-up. There were no cases of the fibrosarcomatous variant.

CONCLUSION

Our data support the growing literature that modified MMS achieves excellent local control for DFSP with a possible benefit of smaller defects when compared with treatment with WLE. The authors have indicated no significant interest with commercial supporters.

Meta-analysis of published data on incompletely excised basal cell carcinomas of the ear and nose with introduction of an innovative treatment strategy

BACKGROUND

Auricular/nasal basal cell carcinomas (BCC) often require more surgical procedures than BCCs at other sites.

METHODS

A meta-analysis of incompletely excised BCCs compares those on the ear and nose to other sites. The combination of photodynamic diagnostics (PDD) and fresh-frozen sections is compared to multi-stage excisions; in each case, the tissue margins were histographically controlled.

RESULTS

The relative risk of an incomplete excision of a BCC on the ear/nose is 2.5 fold higher than on the rest of the body. The combination of PDD and micrographic surgery with fresh-frozen sections reduces the length of stay by 42.86 % from median 14 d to 8 d as well as increasing the revenue per patient per day by 41.9 % from 320.61 euro to 454.95 euro with nearly a comparable rate of recurrences after one year.

CONCLUSIONS

PDD in combination with single-stage surgery is an equivalent therapy with few side effects and conforming to guidelines. It takes into account both quality assurance and patient preferences. Multicenter, randomized trials seem desirable.

[Intra-operative cytopathology: techniques, indications, and limitations]

Intraoperative cytopathology is faster, less labor intensive, yields clearer cellular details and can be as accurate as frozen section in the hands of pathologists experienced in the interpretation of cytological preparations. This procedure is particularly valuable for examining small specimens, multiple samples that need to be examined rapidly, and when superior cytological details are required. Nonetheless its use seems to be relatively limited. In this article, we review the general requirements for intraoperative cytology and also detail its value, as well as its limitations and pitfalls.