Consecutive tissue sections

[Epstein]

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For small biopsies, our histologists usually put 4 levels per slide with a ribbon of two consecutive sections per level. The sections on a ribbon are only microns apart and I have never seen something on one side that wasn't on the other, barring some tissue being rubbed off. I always have treated the extra section as a kind of back up in case the other side was folded or partly rubbed off. If I think the section I'm looking at is adequate for evaluation, I do not typically look at the virtually identical fragment on the other side.

Part of my challenge is that if I look at a second (or sometimes even a third) section that is not appreciably different from the first, my brain considers it busy work and I have a hard time giving it the attention it deserves.

What are you or your staff pathologists doing with these virtually identical sections? Has anyone ever seen a case where the diagnosis would have been missed if only one side was examined?

 

[gbwillner]

What are you or your staff pathologists doing with these virtually identical sections? Has anyone ever seen a case where the diagnosis would have been missed if only one side was examined?

Probably varies between attendings- many will ignore those sections and only look at them if there is an interesting area on the tissue that is not present on multiple levels.... a good example would be "atypical glands" on a prostate Bx, where it appears iffy on one section but is not present on deeper levels.

 

[DrBloodmoney]

One gets 10x treatment the others get 4x (except for prostate and liver where everything gets 10-20x)

 

[pathstudent]

I have seen cases go from benign to malignant on step sections in lung biopsies, so yes I think it does happen. In fact there was one case where someone ordered a recut months later on something and there was cancer on the recut that wasn't on orginal sections. That was kind of a huge deal.

To protect yourself and the patient, I think you need to use common sense. If they are going after a mass and you see normal tissue even on step sections, you order deepers and if there is still nothing, than you can say you did due diligence. Do you need to keep cutting deeper if there is nothing after that? I would say "no" but who knows how many blocks are out there in storage that have significant pathology still in the parafin and not on the slides?

 

[Epstein]

I have seen cases go from benign to malignant on step sections in lung biopsies, so yes I think it does happen.

I'm a big fan of step sections or levels. That's not what I'm talking about. I'm talking about a duplicate tissue section that is only 4 microns away on the same ribbon. The levels are usually about 60-80 microns apart and I definitely look at those and order extras when needed.

My partner looks at every piece of tissue on the slide with the same intensity, even when some of those fragments are virtually identical. It made me wonder if I was practicing below the community standard of care. I wonder if this issue has ever been researched and written up in the literature.

 

[yaah]

You also have to be careful that you know exactly which levels are the consecutive ones. Some labs will cut them so that the consecutive ones go horizontally across a slide, others so that they are vertical. So you can have two rows of three cuts, for example,

A B C
D E F

In some cases A and D are the step sections, in some cases A B C are so that A and D are quite different. This comes into play if you see a lot of outside cases for review.

To me, personally, it depends on the specimen. transbronchs you often have to look at every level closely. Colon biopsies, not so much.

 

[Dral]

I'm only on a 4th year rotation, but I've seen 2 or 3 call changes from benign to malignant in a second section just this week.

Also, I've seen residents and attendings mark a questionable area on a slide and place it under the next slide and mark the second slide to compare the exact area to get a better idea about what's going on. I would have never thought to do that, but it seems like a good idea (not necessary all that often of course).

 

[DarksideAllstar]

I'm only on a 4th year rotation, but I've seen 2 or 3 call changes from benign to malignant in a second section just this week.

Also, I've seen residents and attendings mark a questionable area on a slide and place it under the next slide and mark the second slide to compare the exact area to get a better idea about what's going on. I would have never thought to do that, but it seems like a good idea (not necessary all that often of course).

I'm not certain about the first scenario that you've cited, but the second seems like people were looking at true levels and not consecutive sections.

The only time I like looking at consecutive sections is when something is screwed up with the first (tissue is folded, etc).

 

[Epstein]

I don't doubt that people have identified a significant pathologic finding on the section 4 microns away that was not seen in the initial section. But I bet in each case, you would find the same thing in the initial section.

If someone has an example of a case where a significant finding was present in one section but not present 4 microns away, I'd love to see it. Maybe one of you residents could do a paper on the increased sensitivity (or lack thereof) of looking at every bit of tissue on the slide as opposed to looking at twice at one section per level only.

 

[Dral]

I'm not certain about the first scenario that you've cited, but the second seems like people were looking at true levels and not consecutive sections.

The only time I like looking at consecutive sections is when something is screwed up with the first (tissue is folded, etc).

Yeah I guess what I'm talking about is levels. This has happened on our frozens.