Frozen section request
Intraoperative consultation. First check the specimen is suitable and the result will change the operation.
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PathologyDiagnostic
Frozen Section Decision Making (Intraoperative Consultation)
Frozen Section Decision Making (Intraoperative Consultation): Frozen section request → Not for frozen section: melanocytic lesions, prion disease, TB → ...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Warning Not for frozen section: melanocytic lesions, prion disease, TB
Send these for permanent sections. Tell the surgeon, before surgery if possible.
- Melanocytic lesions (biopsy, excision or margins) and melanoma sentinel nodes: permanent sections only. Freezing lowers accuracy and can miss micrometastases.
- Known or suspected prion disease (CJD): do not cut in the shared cryostat. Follow the lab's prion (TSE) protocol.
- Suspected TB: avoid unless the result is essential. Warn the lab first (staff infection from cryostat work is reported).
03Decision Will the frozen section result change the operation now?
For example: margin, node status, tissue identity, benign or malignant, resectability. The specimen must be suitable (see above).
- If Yes
04Action Yes: frozen section is likely to help
The result changes surgery and the specimen is suitable.
- Surgical margins, where the result changes the excision
- Resectability or an unexpected finding (for example, possible metastasis)
- Tissue identification (for example, parathyroid)
- Ovarian mass: benign, borderline or malignant, to guide staging (borderline tumours are less accurate)
- Adequacy and triage: confirm lesional tissue and keep fresh tissue for ancillary tests (for example, flow cytometry for suspected lymphoma)
- Breast sentinel node: selected cases, per local protocol (often not needed when ACOSOG Z0011 criteria are met)
05Action Specimen handling
Fresh, unfixed tissue, sent straight to the lab with the clinical question.
- Fresh tissue only (no fixative)
- Gross examination guides sampling (sampling causes many errors)
- Thin cryostat sections, H&E stain
- Touch imprint or smear preparations help, especially for brain lesions, lymph nodes and fatty tissue
- Keep enough tissue for permanent sections and ancillary tests
- Process the frozen remnant for permanent sections (frozen section control)
06Decision Can a definitive diagnosis be made on frozen section?
Answer the surgeon's question only when confident.
- If Yes
07Action Yes: give a definitive frozen section diagnosis
Answer the question asked, for example benign or malignant, margin or node status.
- State the diagnosis in plain terms
- Margin: name the margin that is involved or clear
- Record the frozen diagnosis and the time
- The final diagnosis is on permanent sections
08Action Tell the surgeon directly
Speak to the operating surgeon. Confirm the patient and the specimen, then ask them to repeat the result back.
- Direct verbal report to the operating surgeon
- Confirm patient identity and the specimen (site, side) before giving the result
- Surgeon repeats the result, patient and specimen back (read-back)
- Record the result, who received it and the time
- State the limits: final diagnosis is on permanent sections
- Include the frozen section result in the final report
09Action Frozen-permanent correlation (QA)
Compare every frozen diagnosis with the final diagnosis.
- Record each discrepancy and each deferral
- Classify: benign/malignant change, change within category, margin change, node status change
- Find the cause: interpretation, block sampling or gross sampling
- Tell the surgeon if a discrepancy changes care
- Review discrepancies at QA meetings
10End Final report issued
Frozen section and permanent diagnoses in one report.
If No11Action Not definitive: defer to permanent sections
Uncertain, inadequate or needs ancillary tests.
- Atypical cells; cannot exclude malignancy
- Needs IHC or molecular tests
- Poor quality or non-lesional tissue: ask for more tissue if the result still changes surgery
- Rare or unusual lesion
- Tell the surgeon the reason and when to expect the result
- Path rejoins step 08Shared downstream outcome
If No12Action No: frozen section not advised; use permanent sections
The result will not change surgery now, or frozen section accuracy is low for this tissue.
- Tell the surgeon that frozen section is not advised, and why
- Suspected lymphoma: do not subtype on frozen. Adequacy check only; send fresh tissue (not formalin) for flow cytometry
- Thyroid follicular lesions: low yield (capsular or vascular invasion needs permanent sections)
- Soft tissue and bone tumours: do not type on frozen (typing needs IHC). Adequacy check only
- Small specimens that frozen section could use up
- Fatty tissue: freezes poorly and cuts badly
13End Not frozen: process as permanent sections
Report the result in the final pathology report.
Guideline Source
ADASP recommendations for quality assurance and improvement in surgical pathology (2006); exclusions per CAP invasive melanoma protocol v1.2.0.0 (2025) and Cancer Council Australia melanoma guideline
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Not for melanocytic lesions, melanoma sentinel nodes, or suspected prion disease or TB
- Frozen section is less accurate than permanent sections; the final diagnosis is on permanent sections
- Deferral is a safe answer when the diagnosis is uncertain
- Most errors come from sampling or interpretation
Contraindicated Populations
Known or suspected prion disease (CJD)Melanocytic lesions and melanoma sentinel lymph nodes
Applicable Regions
USAUUKEU
AU: Australian labs are accredited by NATA with the RCPA against NPAAC standards. Follow the local intraoperative consultation policy.
UK: Follow RCPath guidance and the local lab policy.
US: CAP Laboratory Accreditation Program requirements apply.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Frozen Section Decision Making (Intraoperative Consultation)?
The Frozen Section Decision Making (Intraoperative Consultation) is a diagnostic clinical algorithm for Pathology. It provides a structured decision tree to guide clinical decision-making, based on ADASP recommendations for quality assurance and improvement in surgical pathology (2006); exclusions per CAP invasive melanoma protocol v1.2.0.0 (2025) and Cancer Council Australia melanoma guideline.
What guideline is the Frozen Section Decision Making (Intraoperative Consultation) based on?
This algorithm is based on ADASP recommendations for quality assurance and improvement in surgical pathology (2006); exclusions per CAP invasive melanoma protocol v1.2.0.0 (2025) and Cancer Council Australia melanoma guideline (DOI: 10.1016/j.humpath.2006.03.010).
What are the limitations of the Frozen Section Decision Making (Intraoperative Consultation)?
Known limitations include: Not for melanocytic lesions, melanoma sentinel nodes, or suspected prion disease or TB; Frozen section is less accurate than permanent sections; the final diagnosis is on permanent sections; Deferral is a safe answer when the diagnosis is uncertain; Most errors come from sampling or interpretation. Individual patient factors may require deviation from these recommendations.
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