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

Disclosures

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

In This Article

Results

Of the biopsies performed during the study period, 1,516 were obtained from 1,395 patients. All analyses and descriptive results were performed on the atypical/malignant cases (n = 785), of which 454 were obtained from the breast/axillary lymph nodes (Table 1) and 331 cases were from the gynecologic tract (Table 2). The total H&E-stained slides for the atypical/malignant cases were 2,355, and the intervening unstained sections were 3,386 slides. The range of tissue sections mounted on the three H&E-stained slide levels was 3 to 12 (mean, 5.4 per case).

Twenty-six cases with no diagnostic material on the first level were identified. Adequate material to unequivocally render a diagnosis subsequently appeared on the multistep level sections on the second (n = 18) or on the third slide (n = 8) Figure 1. The 18 cases that could have been missed if we had not prepared the second level were diagnosed as ADH (n = 7), DCIS (n = 2), ALH (n = 2), metastatic carcinoma in axillary lymph node(s) (n = 2), low-grade dysplasia in the cervix (n = 2), one case each for breast carcinoma, endometrial "atypia," and extramammary Paget disease of the vulva. The eight cases that could have been missed if we had not prepared multistep level sections on the third slide were diagnosed as low-grade dysplasia in the cervix (n = 2) and one case each for ADH, FEA, LCIS, extramammary Paget disease of the vulva, high-grade vulvar dysplasia, and high-grade dysplasia of the cervix. Therefore, an unequivocal diagnosis could have been missed if only one slide had been prepared in 26 (3.3%) of 785 and 8 (1.02%) of 785 if we had not prepared levels on a third slide (Figure 1).

Figure 1.

Significance of adding multistep level sections.

Diagnostic material was present on the first level in 759 cases (Figure 1), of which the material on 101 cases became larger in size while depleted in 6 cases. The 6 depleted cases were 4 breast biopsy specimens with a final diagnosis of ALH (n = 2) and FEA (n = 2), as well as 2 cervical biopsy specimens with a final diagnosis of low-grade (n = 1) and high-grade (n = 1) dysplasia on the second level (the diagnostic material was present on the third level on one breast biopsy specimen with a final ALH diagnosis). When adding a third multistep level section compared with the second level, 13 cases had larger material while the tissue was depleted in 10 cases. The 10 depleted cases were 4 breast biopsy specimens with final diagnoses of invasive carcinoma (n = 1), DCIS (n = 2), and FEA (n = 1), as well as 5 cervical cases with a final diagnosis of low-grade (n = 2), high-grade (n = 2), and indeterminate-grade (n = 1) dysplasia; the last depleted case was an endometrial biopsy specimen with a final diagnosis of atypical endometrial hyperplasia. The positive impact of performing multistep level sections on a second level for all cases was obtained on 119 (15.16%) of 785 compared with 21 (2.68%) of 785 by adding tissue sections on a third level. While 8 (1.02%) of 785 atypical diagnoses could have been missed if no levels had been performed on a third level, the diagnostic material on 10 (1.27%) was depleted (Figure 1).

The average gross sizes of cases with a positive impact to no change for performing levels were 1.54 mm and 1.9 mm, respectively. The average gross sizes in breast cases with a positive impact to no change for performing levels were 1.45 mm and 2.1 mm, respectively. The average gross sizes in gynecology cases with a positive impact and no change for performing levels were 1.55 mm and 1.7 mm, respectively. No statistically significant difference was observed when comparing the gross size of the biopsy specimens with positive impact to those showing no effect of performing levels (P = .404). The average number of the total tissue sections on the three slide levels for cases with no and positive impact of performing multistep level sections was 5.47 and 5.13, respectively, with a statistically significant difference (P = .016).

IHC stains were performed on the intervening unstained sections prepared upfront between the H&E-stained sections (six levels in breast biopsy specimens and two levels in gynecology biopsy specimens) in 26 (3.56%) of 731 benign cases and in 27 (3.4%) of 785 malignant/atypical cases. Breast biomarkers, E-cadherin, myoepithelial markers, gynecology stains (predominantly p16), and other stains were applied on 7, 4, 3, 9 and 4 cases, respectively. Additional recuts were prepared for IHC on 111 (15.18%) of the benign cases and on 380 (48.4%) of the malignant/atypical cases (8 cases had IHC on the intervening unstained sections as well). The intervening unstained sections were used in 3 (20%) of 15 cases with tissue depleted on deeper levels Table 3.

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