The primary function of intraoperative consultation is to provide a tissue evaluation that is as accurate and prompt as possible and to effectively communicate the findings to the operating surgeon to guide subsequent surgical management of the patient [1–4].

To fulfill this function, the intraoperative pathology consultant is expected to provide the following:

Less frequently frozen section evaluation is requested to assess tissue sample adequacy to accommodate the following clinical or diagnostic considerations [2]:

Considerations to perform frozen section diagnosis may also include:

However, there is no standardized practice for surgeons in requesting intraoperative consultation. Indications for frozen section evaluation vary significantly among institutions and even among gynecologic oncologists within the same institution. In principle, a request for intraoperative consultation is acceptable if a tissue sample is submitted with a question for an answer, upon which a real-time clinical decision has to be made for subsequent surgical or medical management of the patient [2, 5]. It is important that the frozen section remains relevant only in the context of broad medical knowledge of the pathologist and judicious utilization by the surgeon, both for the ultimate patient care [6].

Prior to examination of the specimen, careful review of the clinical information and understanding of the clinical expectations for frozen section are crucial for a successful intraoperative consultation. Many specimens are submitted for intraoperative consultation with a specific clinical question, which should guide the initial gross examination to identify the lesion of interest. When the clinical indication is unclear or the orientation of the specimen cannot be determined with certainty, prompt communication with the operating surgeon may be necessary to identify the lesion and to take appropriate tissue sections for frozen section evaluation.

As a real-time engagement between surgeons and pathologists, frozen section diagnosis frequently offers the most decisive consultation during surgery. Concordance between the frozen and the final histological diagnoses ranges from 96.5 to 98.5 % in the general pathology practice [7–9] with mean and median concordance rates of 96.8 % and 97.4 %, respectively [8]. Common reasons for diagnostic discordance include misinterpretation of the frozen section (interpretation error), presence of diagnostic tissue only on the permanent section of the frozen tissue block, and diagnostic tissue in the portion of the specimen not sampled by the frozen section (sampling error) [9].

In diagnostic gynecologic pathology, frozen section evaluation is an important tool to assess the local tumor spread and therefore to guide intraoperative decision-making regarding the necessity of lymphadenectomy and/or omentectomy for patients with endometrial cancer. High concordance between the frozen section and final permanent section diagnosis has been consistently reported with concordance rates of 88–89.9 % for tumor grade, 85.4–98.2 % for depth of myometrial invasion, 100 % for cervical involvement, and 92.4 % for lymphovascular invasion [10–12]. In ovarian lesions, the overall accuracy of frozen section diagnosis ranges between 80.7 and 97.1 % for primary [13, 14] and between 78.8 and 90 % for metastatic tumors [15, 16].

Although pathologists should make the best attempt to provide a diagnostic interpretation as precisely and quickly as possible, the frozen section evaluation cannot be thorough in many cases. The inherent limitations of frozen section diagnosis need to be carefully considered and communicated adequately between pathologists and surgeons. Significantly different from routine pathology diagnosis using formalin-fixed paraffin-embedded tissue preparations, frozen section evaluation is limited by suboptimal tissue quality, tissue processing (freezing and cutting) artifacts, often different tissue staining qualities, time restraints, and lack of ancillary study tools. Other significant factors affecting intraoperative consultation include the pathologist’s experience, the need of consulting additional pathologist(s)/subspecialty pathologist, involvement of pathology trainees, availability of preoperative diagnostic materials, concurrent multiple frozen sections, and technical issues (e.g., instruments, technical skills of the staff) [17].