FINAL DIAGNOSIS:
LIVER (NEEDLE CORE BIOPSY)
- Chronic Hepatitis with mild activity (Grade 2 of 4)
- Portal fibrosis (Stage 1 of 4)
(What is Liver Fibrosis:
Fibrosis is excessive accumulation of scar tissue that results from ongoing inflammation and liver cell death that occurs in most types of chronic liver diseases. Nodules, abnormal spherical areas of cells, form as dying liver cells are replaced by regenerating cells. This regeneration of cells causes the liver to become hard. Fibrosis refers to the accumulation of tough, fibrous scar tissue in the liver.)
MICROSCOPIC EXAM:
Microscopic sections of the needle core biopsy demonstrate two cores of liver parenchyma (the functional part of the organ) with an overall intact architecture. There are approximately thirteen portal tracts (Portal tracts: These are islands of connective tissue containing branches of the portal vein and hepatic artery, running side by side, that bring blood to the sinusoids. They also contain bile ducts, which carry bile in the opposite direction to the blood flow.) present for review. The portal vasculature and bile ducts appear unremarkable. Most of the portal tracts are expanded by a lymphocytic infiltration with ocasional spillover. In addition, scattered lymphocytes are found in the lobules. Few apoptotic hepatocytes are noted. (Hepatocytes: These are parenchymal cells that form plates. They are the main functional cells of the liver. Apoptotic Hepatocytes indicate acute liver damage.) There is minimal macrovesicular steatosis estimated at less than 1%. (Macrovesicular steatosis is the most common form and is typically associated with alcohol, diabetes, obesity and corticosteroids.)
The trichome stain highlights mild fibrous expansion of the portal areas. There is no bridging fibrosis. The PAS stain with and without diastase highlights the above finding. No alpha-1 globules are seen on the PAS with diastase stain. The iron stain shows no increase in iron deposits. The reticulin stain highlights 1-2 cell thick plates.
GROSS DESCRIPTION:
The specimen is received in formalin in a container labeled with the patient's name (that's me!), medical ID number and designated as "liver biopsy." It consists of two cylindrical tan-brown-white tissue fragments <0.1 cm in diameter x2.0 cm and 2.3 cm in length. The entire specimen is submitted in a biopsy bag.
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| Not A Lot Of Fun: Liver Biopsy Image Courtesy of the Mayo Clinic |
For those of you with scientific minds and medical degrees...
Nomenclature, grading, staging of liver biopsies
A recommendation to replace the old terminology for chronic active and chronic persistent hepatitis (Popper, 1971; Rev International Group, 1968) is now becoming widely accepted for a variety of reasons (Gerber, 1992; Ludwig, 1993; Scheuer, 1986). The new nomenclature would use "chronic hepatitis" with the addition of a grading of activity of the hepatitis based on the degree of inflammation and necrosis and the stage of fibrosis. The terminology will also include the etiologic agent or cause, if known (International Working Party, 1994).
Several grading and staging systems have been proposed that use a variety of scores (Bedossa, et al, 1994; Desmet, 1994; Ishak, et al, 1995; Ludwig, 1993; Scheuer, 1991). Many of these systems have been modified from Knodell, 1981. Examples of a simple and a somewhat more complex system are given.
System adapted from Ludwig, 1993
Portal and Lobular Inflammatory Activity
0 None or minimal portal inflammation, no necrosis
1 Portal inflammation chronic persistent hepatitis without necrosis and/or lobular inflammation without evidence of necrosis.
2 Mild limiting plate necrosis (mild chronic active hepatitis) and/or focal lobular necrosis.
3 Moderate limiting plate necrosis and/or severe focal cell damage
4 Severe limiting plate necrosis and/or bridging necrosis.FibrosisStg 1 No fibrosis or confined to enlarged portal zones
Stg 2 Periportal or portal-portal septa but intact architecture
Stg 3 Septal- fibrosis with architectural distortion; no obvious cirrhosis
Stg 4 Probable or definite cirrhosisSystem adapted from Ishak, et al, 1995
Necroinflammatory Scores
Score Pathology
A. Periportal or periseptal interface hepatitis (piecemeal necrosis) 0 Absent
1 Mild (focal, few portal areas)
2 Mild/moderate (focal, most portal areas)
3 Moderate around less than 50% of tracts or septa)
4 Severe continuous around more than 50% of tracts or septa
B. Confluent necrosis 0 Absent
1 Focal confluent necrosis
2 Zone 3 necrosis in some areas
3 Zone 3 necrosis in most areas
4 Zone 3 necrosis, plus occasional
portal-central (P-C) bridging
5 Zone 3 necrosis, plus multiple P-C bridging
6 Panacinar or multiacinar necrosis
C. Focal (spotty) lytic necrosis, apoptosis and focal inflammation
0 Absent
1 One focus or less per 1Ox objective (ob)
2 Two to four foci per 10x ob
3 Five to ten foci per 10x ob
4 More than ten foci per 10x ob
D. Portal inflammation
0 None
1 Mild, some or all portal areas
2 Moderate, some or all portal areas
3 Moderate/marked, all portal areas
4 Marked, all portal areas
Architectural Changes, Fibrosis/Cirrhosis
0 No fibrosis
1 Fibrous expansion of some portal areas, with or without short fibrous septa
2 Fibrous expansion of most portal areas, with or without short fibrous septa
3 Fibrous expansion of most portal areas with occasional portal to portal (P-P) bridging
4 Fibrous expansion of portal areas with marked bridging (P-P as well as P-C)
5 Marked bridging (P-P and/or P-C) with occasional nodules (incomplete cirrhosis)
6 Cirrhosis, probable or definiteAnd that's how the liver bounces...
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