Day 85 Night - Let's Get A Little Medical Because That Whimpering Son Of A Bitch Is Trying Not To Complain Or Even Itch Tonight

Here is the Surgical Pathology Report about my Liver Biopsy (9-1-2011) from the Department of Pathology and Laboratory Medicine at Olympia Medical Center. I added all the parts in italics that help to describe terms and words that were difficult to me to understand. This is how we began...

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.

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.

Fibrosis

Stg 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 cirrhosis
System 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 definite

And that's how the liver bounces...

Day 18 Night — Clinical Trials First Step: A Very Cool Nurse And Element Girl

Okay, as with everything in this hyper-intensified process, I perambulated today between deep spirituality and freaked-out crisis like a pinball doing the dance of life and death. My first meeting at the medical office buildings across from Olympia Medical Center for the clinical trials took place, and it was an overall positive with hints of lurking negatives. What is essential is not to fall into the either/or perspective and to understand that I am not dancing between darkness and light, good and evil, or life and death, but lingering in a vast amorphous landscape of grey. The grey offers no easy choices beyond murky fears and no quick solutions, but at least it reflects a certain truth in terms of the nature of reality and human life. There are very few mythic battles and transcendent confrontations. There are mythic hearts and transcendent laughter, and they do battle with the grim truth of everyday reality like the rest of us. Mind you, I have not forgotten that there is beauty and wonder everywhere if you look with clear eyes and open hands.

The Dream of the Mythic Battle Against Monstrous Evil

When I went into the clinical trials, I met Chris Rice, the RN who is the clinical manager of the project. Later, I will go into more details about the clinical trials, but there will be plenty of time for that in the future. Besides being incredibly positive and user-friendly (sounds like a massage with a happy ending) on the phone, Chris presented the details of the trials with precision and understandable specifics. When I went into the office today and Chris took all my medical data and history, we got along incredibly well. Since we are both huge comic book fans, it was wonderful to hear about how he is sharing Neil Gaiman's brilliant Sandman with his 15-year old daughter.

Neil Gaiman's Sandman - Facade (Death of Element Girl)

I have no kids and I have tons of comic books and baseball cards, and I always thought I would pass them down. Maybe I'll have a child in the future - being a man, the ticking clock moves a bit slower - but if I don't, I can always share them with my nephews and my niece. When Chris described watching his daughter read some of my favorite stories from Sandman, I must admit I was deeply moved by vicariously experiencing something I once dreamed of doing myself. In particular, there is one issue called Facade about the despair of the super heroine Element Girl, an eternal metamorpho created by Ra, the ancient Egyptian God of the Sun. Element Girl can change into any element at will and she is incredibly powerful, but she longs for the release of death. Since she naturally changes into any element to adapt to any situation, she does not know how to kill herself and end her overwhelming sense of being an alienated freak. She is surprised when she is unexpectedly visited by Death, one of the Endless.

Death Visits With Element Girl In Her Moment Of Despair

Element Girl is told by Death that all she has to do is ask Ra to release her from life. But how, she asks, do I find him? She is told that Ra is a Sun God so all she has to do is look into the sun and ask nicely. She walks over to the window as the dawn approaches and the sun is rising, asking Ra to free her from the burden of her powers. In a stirring moment, Ra releases her from the eternal battle and she dissipates into dust with her ashy smile blowing away on the breath of the wind. It would be wonderful to watch my child experience such a beautiful story that meant so much to me. But I feel no regret right now; only happiness that I was able to empathize so deeply with a real-life experience and story told. There is more to tell about the doctor and the looming lesion in my kidney and a questionable high five, but that shall come later because there are more days and nights coming for me. I have no desire to have Ra free me from the blessing of this life, and I shall fight to hang on with your help.