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

Materials and Methods

Following approval from the institutional review board, all in-house breast and gynecology biopsy specimens accessioned between January 18, 2019, and January 29, 2020, were retrieved. All H&E-stained sections and the final pathology reports were reviewed. Roswell Park Comprehensive Cancer Center is a comprehensive cancer institute located in Buffalo, New York, which serves a diverse population from multiple geographic locations, particularly upstate New York, with subspecialty sign-out at the pathology department. At our laboratory, all biopsy specimen grossing is carried out by pathology assistants under the supervision of pathologists. At our histology division, multistep level sections of nine slides, with 4-μm-thick sections, are routinely obtained on breast biopsy specimens after the initial effacement of the paraffin blocks to obtain a uniform surface. Slides 1, 5, and 9 are stained with H&E, and the intervening six unstained sections are saved for further studies, if needed. For gynecology biopsy specimens, multistep level sections of five slides are routinely obtained. Slides 1, 3, and 5 are stained with H&E, and the intervening two unstained sections are saved for further studies, if needed. The laboratory discards 50-μm-thick tissue in between the slides except for very small biopsy specimens (1 mm or less), where a continuous ribbon is divided between the slides with no discarding of tissue. However, no specific protocol has been adopted on the number of tissue sections to be mounted on each slide. In this study, statistical comparisons were performed using the Student t test, with P < .05 considered significant.

The H&E-stained multistep level sections were examined, and the diagnoses for the breast cases were categorized into (1) benign (including fibroadenomas, papillomas, and radial scars) (n = 393), (2) atypical (atypical ductal hyperplasia ADH, flat epithelial atypia [FEA], and lobular carcinoma in situ [LCIS]/atypical lobular hyperplasia [ALH]) (n = 72), and (3) malignant (carcinomas, ductal carcinoma in situ [DCIS], and other malignancy) (n = 382) Table 1. The diagnoses for the gyn cases were categorized into (1) inadequate (n = 32), (2) benign (n = 276), (3) dysplasia and hyperplasia (for the lower female genital tract and the endometrium, respectively) (n = 220), and (4) malignant (n = 111) Table 2. The diagnostic material on the H&E-stained slides was categorized into (1) present if the material was unequivocally enough to render the diagnosis, (2) decreased/diminished in size if the tissue on the subsequent slide was inadequate to render the diagnosis, (3) increased in size if the tissue was readily increased in size compared with that in the preceding levels, (4) absent on the tissue sections on the first slide, and (5) depleted on the subsequent sections if the material was completely absent or significantly small in size to render a diagnosis without the previous sections. Performing multistep level sections has a positive impact if the diagnostic material increased in size or was present on subsequent section(s) of an inadequate initial level(s). To document whether multistep level sections positively affected diagnosis, the tissue sections in the second slide were compared with the first slide, and the tissue sections in the third slide were compared with the second slide. Utilization of the intervening unstained sections and/or preparing additional sections for immunohistochemistry (IHC) has been analyzed. All cases with more or less than three H&E-stained slides were excluded from the study.