Intraoperative investigation of sentinel lymph node has the advantage to circumvent a secondary surgery. In cases with histological sentinel lymph node metastases, a simultaneous axillary dissection can be performed by the surgeon.

According to the literature, different analyses assigned frozen sections of sentinel lymph nodes a false negative rate of results [1–5]. Based on reduced specificity and sensitivity as well as limited possibility to supplementary immunohistochemical analysis, the S3-guidelines do not recommend a layered cut of sentinel lymph nodes in frozen sections [6, 7]. In contrast, a combined procedure of alternating frozen section and paraffin reprocessing guarantees a high specificity of nodal status assignment. Referring to this, a sentinel lymph node is laminated in slices of 0.2 cm vertical to its longitudinal axis and alternating slices are either paraffin embedded or frozen sectioned. From each slice at least 8 layered cut were produced (Fig. 2). In a series of 229 sentinel lymph nodes, a concordance in the technique of alternating slices of 97.9 % could be realized, in contrast to the so called OSNA-technique with a concordance of 90 % between lysate and frozen section as well as lysate- and paraffin-embedded tissue.

For prognostic molecular biologic analysis like ELISA-produced proof of uPA and PAI-I as well as for innovative diagnostic testing, asservation of unfixed native tumor tissue is recommended [8]. According to interdisciplinary guidelines, asservation of native tissue is restricted to institutions of pathology to warrant a standardized investigation of the tumor (Fig. 3).

According to the aforementioned Oxford criteria and guidelines of the Arbeitsgemeinschaft gynäkologische Onkologie (AGO)—an indication for immediate pathological analysis (including frozen sections) is given in cases with a lesion taller than 1 cm without a core biopsy, to clarify dignity in preoperative uncertain situations, the assessment of representativeness, the histological investigation of the retromammillary region, and the investigation of the surgical resection margins (Fig. 1 and Table 1).

Particularly, the investigation of resection margins by immediate pathological analysis helps to circumvent secondary surgery—which is declared with 15–50 % [9, 10]. Also therapeutic options like immediate reconstruction or intraoperative radiotherapy (IORT) depend on reliable information of surgical resection margins [11, 12] and especially IORT needs—according to the Targit study [9, 13]—a residual tumor-free resection in a one-time intervention.

Different methods are exercised in immediate pathological analysis [9, 10, 12, 14–19]. In our experience a timesaving macroscopic supported (Fig. 3) safety distance of 1 cm could reduce the rate of secondary surgery from 21.4 to 9.1 % with a negative predictive value of 97 % [11, 20].

According to the aforementioned Oxford criteria and guidelines of the Arbeitsgemeinschaft gynäkologische Onkologie (AGO)—no indication for immediate pathological analysis is given in cases with a non-palpable or less than 1 cm measured lesion, a clarification of dignity in corebiopsies and B3 lesions as well as an investigation of resection margins in DCIS (Fig. 1 and Table 1). Moreover, a recently published study showed a guideline controversy surgeon-dependent variety of practice patterns for handling surgical margins in breast conservation treatment [21]. In all these cases, formalin-fixed specimen have replaced native tissue specimen investigation and thus fresh tissue asservation was hampered in the last years.

In order to warrant fresh tissue asservation for biomarker analysis and tumor banking of all mammary resection specimens, the Medical School Hannover (MHH) uses in addition to immediate pathological investigation the possibility of vacuum-fixed processing of every native breast specimen for an indication-dependent pathological investigation algorithm (Fig. 4).