byq - thank you very much! I didn't mean that you need to provide the information to my questions.  But, the information should be useful to all the readers. Breast cancer is a huge problem in China and the world. It affects many young and middle aged women. I trust that the practice in China will be more evidence-based, guideline-driven, and more in line with the western standards in the next few years. 

Thanks 曹大夫 and 力刀 for the comments and support.

It's unlikely that the routine frozen section practice in China will change in a short time. The only way to avoid mistake is to get well trained in breast pathology, when you in doubt - get consultations, be conservative, tell the surgeons that "it is difficult to be certain, wait for permanent paraffin sections"

Thanks for Dr. Yuexin and Dr. Lili0321's comments.  I have read some of the other discussions and comments in previous postings in frozen and breast sections, particularly by byq and  Dr. 力刀. Here is a summary and hope this will be helpful for your practice.   If intraoperative frozen section is required, we have to realize it is a dangerous area for making diagnosis, get well trained and be conservative and avoid some of the common pitfalls and mistakes.  We welcome comments form colleagues from China and US.

Current diagnostic and treatment flow for breast lesions in US

·          Patient had abnormal mammographic finding (microcalcification), mass/nodule or nipple discharge

·          Core needle biopsy for routine H&E stain and diagnosis, also for ER/PR/Her-2/neu stains

·          Confirmed by pathologist to be benign or malignant (in situ or invasive carcinoma)

·          If benign, discussion with patient –  options are surveillance or conservative excision

·          If malignant, plan for appropriate surgery either by lumpectomy or mastectomy with or without sentinel

Lymph node biopsy with or without axillary dissection for staging

·          Planning for Rx or chemotherapy based on diagnosis, TNM stage and other risk factors

Potential problems with frozen section of breast lesions

·          For small mass lesion, easily to be lost during freezing and cutting

·          For non-palpable (microcalcification), sampling for frozen a huge problem

·          Very poor quality slides and frozen artifacts

·          Difficult for pathologist to make a accurate diagnosis  

·          The results are unacceptably high false negative and false positive or deferred diagnosis

 (Very rare frozen dx for breast lesion in US!)

Current practice in the smaller community hospital in China (thanks to byq)

·          乳腺包块的病人到医院来了

·          临床医生开个单子叫他先到病理科做细针穿刺 (fine needle aspiration cytology – cannot differentiated DCIS or invasive carcinoma)

·          如果有问题 (suspicious for DCIS or Invasive Ca)，临床医生就让病人住院手术 (what if not diagnostic, benign, atypical hyperplasia or DCIS or LCIS, what next?)

·          术中为了保险起见，(incisional biopsy specimen?), 做个冰冻 (if confirm malignant – DCIS and invasive?) 再把乳房切掉 (breast conservation surgery or not?)。

·          What about if frozen diagnosis is benign? What’s next

·          现在对乳腺癌的治疗提倡新辅助化疗 (neoadjvant chemotherapy): what the inclusion criteria?

国内开展粗针活检还不是很普遍，原因是多方面的:

Ø       一是耗材较贵 (did anybody actually perform a comparison cost analysis with current practice)

Ø       二是粗针穿刺标本也是很小的标本，出现漏诊的几率据报道可达7% (where are the data from?)

Ø       标本送到病理科我们感觉组织太小 (size of core and number of core, bx technique)

Ø       做起来非常困难 (diagnostically)，切片出来有时候根本看不到肿瘤细胞，

Ø       No tissue left for下一步要做免疫组化染色等也就无从做起

Do we need to and how to improve the breast cancer care in China

Ø       First we have to have evidence to support that the practice in US and Europe are better for the patient care

Ø       Cost-benefit analysis comparison between current practice in China and standard practice in US

Ø       The conclusion may be frozen diagnosis may be acceptable and practical in China

Ø       Identify what are the challenge areas for adoption of abandoning routine frozen section

o         Core biopsy (by radiologist or surgeon)

§          Biopsy equipment and instrument

§          Size of cutting needle

§          Experience and training (radiologist or surgeon)

o         Diagnostic skill (pathologist training)

§          Training course

§          Pitfalls and problems

§          Clinico-pathologic-clinical correlation

This is an article published last year and I will read it also.  I will post a few other articles from Europe and US and hope they are helpful to you.  

Niu Y, Fu XL, Yu Y, Wang PP, Cao XC. Intra-operative frozen section diagnosis of breast lesions: a retrospective analysis of 13,243 Chinese patients. Chinese Medical Journal, 2007, Vol. 120 No. 8 : 630-635 (From Tianjin Cancer Institute, Tianjin Medical University, Tianjin, China.)

BACKGROUND: Although cytological methods for breast oncology have been used in recent decades, intra-operative frozen section has been playing a vital role in making therapeutic decisions. We analyzed a large series of frozen section diagnoses for Chinese cases of breast lesion within the last 15 years. The experience was expected to increase the diagnostic accuracy of cases with breast lesions. METHODS: The data from consecutive 13243 cases of breast lesions diagnosed with intra-operative frozen sections between 1988 to 2002 were compared with paraffin sections in a case by case manner. The causes of false negative and positive diagnoses as well as delayed diagnoses were analyzed. RESULTS: One hundred and seventeen cases (0.9%) were falsely diagnosed, with one false positive case and 116 false negative cases. The diagnosis of 47 cases (0.4%) was delayed. The proportion of several lesions had the features of the patients' ages. Six types (false invasion, peri-papilloma, adenoma of nipple duct, florid adenosis, sclerosing adenosis, and granulose cell tumor) of lesions may lead to false positive, and four types (morphological changes responding chemotherapy, well differentiated papillary carcinoma, invasive lobular carcinoma, and tubular carcinoma) to a false negative. Gross and microscopic findings may be inconsistent in two types of lesions (radial scar and florid adenosis) microscopic and clinical findings in three types (ganulomatous mastitis mammary, duct ectasia, and fat necrosis), and three types (abundant fat or sclerous tissues; borderline lesions and changes of post-chemotherapy) were likely wrongly classified. CONCLUSIONS: Intra-operative frozen section can accurately identify breast lesions in many instances, leading to fewer errors on account of more diagnostic experience and understanding of diagnostic limitations.