Comments from Dr. G pathologists

[JungleHeart]

Thought I'd move this to a new thread since it's a different subject.  I got a copy of this yesterday.  It is Dr. Gish's pathologists' best shot given that there were not enough samples and that those they did have were fragmented.  Hector?  Anyone?  I will get another bx done soon - but not here locally.  The issue now seems to be finding a hepatologist - another one in Vegas.  

COMMENT
Provided for our review is a suboptimal fragmented liver biopsy with only five portal tracts.  Portal tracts are remarkable for inflammation comprised predominantly of lymphocytes with occasional scattered eosinophils and plasma cells.  Scattered acidophal bodies are also noted throughout the biopsy specimen.  Please note that this biopsy is limited and thus grading may not be accurate.  In this limited, fragmented biopsy, trichrome stain shows features worrisome for bridging fibrosis, possibly cirrhosis.  

Grade:  7 of 18 points

Stage:  see comment

Portal inflammation (Pl): 3, Moderate/marked, all portal areas

Focal (spotty) lytic necrosis, apoptosis and focal inflammation (LA); 2, 2-4 foci per 10x objective

Periportal or periseptal interface hepatitis (piecemeal necrosis) (lA): 2, mild to moderate (focal, most portal areas)

Confluent necrosis (CN): 0, absent

Fibrosis:  see comment above

Adequacy:  Length of biopsy is 1.3 cm.  Number of portal triads: 5

Steatosis:  1-% steatosis with azonal distribution

Stainable iron:  not provided for our review

PASD:  Not provided for our reveiw

(p.s.  I apologize if I have been presenting erratically)

[Idyllic]

Oy. I am with Hector on this one. I am all for the good ol' college try but I think twice before putting much stock into info that starts with:

"Provided for our review is a suboptimal fragmented liver biopsy..."

and ends with

"Please note that this biopsy is limited and thus grading may not be accurate.  In this limited, fragmented biopsy...."

[JungleHeart]

Thank you, Hector.  We can let this thread disappear.  Appreciate your feedback.  Biopsy as soon as I can get one.  Too bad it has to happen, but it does.

Peace

[HectorSF]

It is hard to draw any conclusion since "this biopsy is limited and thus grading may not be accurate.  In this limited, fragmented biopsy, trichrome stain shows features worrisome for bridging fibrosis, possibly cirrhosis."  

Without the proper length and the proper number of portal tracks the results can be wildly inaccurate. I wouldn't put any weight on this biopsy. Get another biopsy soon. It only should take a week or two to schedule a biopsy. Then we will go from there.

Technically speaking here are the detail regarding specimen size and quality...

AASLD POSITION PAPER
Liver Biopsy
This position paper has been approved by the AASLD and represents the position of the association.

http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/Liver%20Biopsy.pdf

"In order to justify the inherent risk in the procedure, it is essential that the resulting liver biopsy specimen be adequate so as to allow detailed interpretation. This almost always means that the biopsy should be of large enough size to view a representative amount of parenchyma and number of portal tracts (an adequate number of portal tracts has been proposed to
be greater than 11); the number of portal tracts is proportional to biopsy size.
..., it must be emphasized that in nearly all liver diseases, parenchymal abnormalities are irregularly distributed, and sampling variability is almost inevitable.
...steatohepatitis could not be distinguished from simple steatosis in 14% of cases.
...Studies in patients with viral hepatitis have shown that grading and staging accuracy is reduced in biopsies less than 2.0 or 2.5 cm in length.
...Although a 1.5 cm biopsy specimen may be adequate for assessing many liver diseases, short specimens may result in difficulties in patients with cirrhosis. Such short specimens may lead to a failure to recognize cirrhosis in up to 20% of cases. To assess for the presence of cirrhosis, cutting needles are superior to suction-type needles.

Thus, long and wide (an ideal size is 3 cm long after formalin fixation obtained with a 16 gauge needle) biopsies are desirable (this may also help justify the risk-benefit of the procedure despite the possibility that the risk associated with use of a larger needle may be theoretically greater) and if cirrhosis is suspected, a cutting needle rather than a suction needle should be used.

So when you get the new biopsy report and then we can look at it and and translate it for medical language into term we can all understand.

Ciao
Hector

[JungleHeart]

sorry - that should have been 10% steatosis