Diagnostic Utility and Significance of Performing Multistep Level Sections in Breast and Gynecologic Biopsy Specimens

Al Amin, MD; Sayeeda Yasmeen, MD, MPH; Devi Jeyachandran, MD; Thaer Khoury, MD; Mohamed Mokhtar Desouki, MD, PhD


Am J Clin Pathol. 2021;156(4):620-624. 

In This Article

Abstract and Introduction


Objectives: The significance of performing multistep level sections, including preparation of unstained sections in breast and gynecologic biopsy specimens, has been studied.

Methods: Consecutive H&E-stained level sections of 785 atypical and malignant biopsy specimens were included. The diagnostic material was categorized into present, absent, increased in size, or depleted. If the multistep level sections helped in establishing the diagnosis after a nondiagnostic material or the tissue significantly increased in size, this was considered a positive impact.

Results: No effect and positive impact of performing multistep level sections were obtained in 84.8% and 15.2% by preparing a second level and 97.2% and 2.8% by preparing a third level, respectively. Eighteen (2.3%) of the diagnoses could have been missed without performing a second level, while 8 (1%) could have been missed without performing a third level. The intervening unstained sections were used in 27 of 785 (3.4%) of the cases.

Conclusions: Staining two level sections with H&E significantly affected the diagnosis. However, preparing a third level did not improve the diagnosis. A universal protocol should be considered to standardize the handling of biopsy specimens among laboratories.


Sampling lesions for histopathologic diagnosis is the standard of practice and is an essential procedure to diagnose, apply predictive and prognostic markers, and decide the next step of the patient's management, among other benefits.[1] Clinically palpable lesions (eg, skin lesions) are usually accessible for biopsy, with most cases not requiring radiologic assistance. However, deep-seated lesions may benefit from radiologic and/or other techniques, which assist in selection of the target lesion. For example, mammographic, ultrasound, and magnetic resonance imaging–assisted breast core needle biopsies are well known and widely applicable in daily practice.[2] Colposcopic cervical biopsies and curettage are also well known in the field of gynecology and obstetrics.[3]

There is a fine line between obtaining a small piece of tissue, which preserves the functionality of the organ, and having an adequate amount of material by which to render an accurate diagnosis and apply ancillary studies, if needed. Selecting the correct instrument to perform the biopsy (eg, the appropriate gauge of the needle and performing the adequate number of cores) is a critical exercise for the operator to achieve that balance (operator-centered factors).[4] On the other hand, the laboratory has the responsibility to use the material received efficiently to render the diagnosis, preserve the tissue for workup without compromising the diagnosis, and efficiently use the financial resources (laboratory-centered factors).[5]

When dealing with biopsy specimens, which are often small specimens, one of the standard practices is how much to prepare for morphologic examination (mostly by H&E stain). Effacing the paraffin block will lead to tissue loss, which may prompt depletion of the tissue, even prior to diagnosis.[6] Therefore, laboratories apply different protocols to efficiently use the material received (eg, preserving the tissue curls during effacing the blocks and in between the levels, and cutting multiple levels/slides starting as soon as the tissue appears during effacing the block).[3]

Unfortunately, there is no standard protocol for preparing tissue sections from biopsy specimens for morphologic diagnosis. In addition, there is a wide range of pathologist preference and requisition for additional deeper sections, even among pathologists in the same practice. The aims of the study were to test the diagnostic utility and significance of performing multistep level sections and assess how many tissue sections per each level in breast and gynecology biopsy specimens in broad diagnostic categories at our institution.