Biopsy ? / jmjm & others

[copyman]

i'm scheduled to have a bx in sept. i just found out that my doctor who is going to do it does not use unltasound guided bx. can someone explain what the difference is? is it more dangerous to have it not US guided? please explain the pros & cons. i was told by the docs nurse that if i wanted a "guided" bx then i would have to have a radiologist do the procedure. i'm a nervous wreck as it is about getting a bx and then to hear this about he does the bx "blind". i have been putting bx off until i found out that the FibroSCAN has me between a F1 & F2 and FibroSURE 10 months ago had me at F0! now i want the bx for the real answer. thanks for the help

[jmjm530]

Let me preface my remarks by saying that my last biopsy was five years ago, so maybe things have changed, but I don't think so.

Against popular wisdom here, all of my 4-6 (can't remember) biopsies since 1968 were unguided. Other than local, no premeditation was used that I remember and all but one was over so quickly (about a second) that I had to ask the doctor each time if it was over. And except for the first one (by some resident who seemed like he was in me for five minutes), they were all performed by arguably some of the best hepatologists in the country. That's the way these guys did them and they performed thousands each.

My suggestion is not to focus on the technology but to focus on finding a good hepatologist who has done thousands of them and let him do it the way he/she is used to.  There is usually one or two "best" at every large, teaching hospital with a liver center. That's the person you want to jab you and not necessarily someone with far less experience using US.

-- Jim

[mikesimon]

I have had both types and I prefer the ultrasound guided by far. I don't care who does them as long as they hit the liver and get a good sample. I care far more about who read the slides than about who gets the samples. But, if all you can get is what I call the "bedside" type I think that's perfectly alright. I had 4or 5 of them and they weren't bad at all. The ultrasound guided ones I got (3) were with a spring loaded core retrieval gun and the radiologist went in just below my sternum and they were a snap - literally and figuratively. It's like a nail gun and that is my favorite type. I just had another one last June on my birthday and it made for a splendid birthday present - sort of. If you can get an ultrasound guided one I would but if it's inconvenient or impossible/impractical I wouldn't worry. You'll have to lie there for 3 hours afterward regardless of which type you get and for me that was the hardest part anyway. Good luck, Mike

[jmjm530]

I guess the other question is why do you feel you need a biospy with an FO Fibrosure and a scan of F1&F2. Did doctor A. suggest you have one? If the question wasn't asked, you might email me him for his opinion. An alternative might be follow-up Fibroscans on a yearly basis, be it in Boston or more local, as they should be more local at some point.

-- Jim

[copyman]

thanks for the responses,

jm, Dr A did suggest i get the bx to see exactly where i am and besides that he needs the result for the FS trial. if you remember he had told my doc here in Nj that i could not get it without a bx 6 months before or after. what is your take on the difference in a mere 10 months with my F-sure & F-scan. do you think i could have progressed that fast? Dr A said no. my labs have stayed pretty much the same, alt around 50 & ast 26-35. plates 200. everything else normal except lipids out of whack. i have had bloodwork about 15 times in the last year nothing much changed. neg cat scan & US. also had that new test, CRS (cirrhosis risk score) and that had me 3x the norm to advance to cirrhosis, this has me worried some. although Dr A grinned and said that test was a waste of money.
he did give me his email address, did you ever email him? does he respond? i feel like i would bother him to send him email. thanks

mike, i will look into the US guided bx. thanks

[jmjm530]

I'm sure he'd respond to your email but you're placing him, your doctor (and yourself) in a tough spot since he wasn't supposed to give you a scan unless you committed to a biopsy.
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What I meant was that it may be awkward asking him if you really need a biopsy or if he needs your data. The truth may lie somewhere inbetween.

[jmjm530]

Copy: Dr A did suggest i get the bx to see exactly where i am and besides that he needs the result for the FS trial.
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Two issues and the possiblity exists there may be a conflict of interest. I was discussing the need for biopsy irrespective of the FS trial. I'm sure he'd respond to your email but you're placing him, your doctor (and yourself) in a tough spot since he wasn't supposed to give you a scan unless you committed to a biopsy. Of course, one can always change their mind, but I'm afraid you might have to look elsewhere for advice and I'm not sure where as he's pretty much the man with the scan in your neck of the wood.

Copy: said that test was a waste of money.
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What test? F-sure? CRS score?

[FlGuy]

If he said that the results of the bx are for two purposes (tell you where you are and as compare to FS) you have two reasons to do the bx.  I get the drift that you either implied, or expressly agreed, to the bx under the 'FS Trial' parameters.  Not sure.  But if you feel that it was the implication in seeing A and getting the FS, then you should.  IMO.  In the end, the benefit of the fs and the bx could be farther reaching than just you.  My two cents.

[copyman]

jm, i did not mean i would email Dr A to ask about getting the BX, i meant for questions in the future. to be truthful i did not have intentions on getting the bx, i just wanted the scan and that is why i scheduled bx before going to boston. i was gonna cancle the bx appointment but with what the scan results showed i want it now. the bx results will determine if i tx or not. F1 wait F2 treat.
the reason i would treat with F2 is i'm scared that i may be a fast progressor, if the fibrosure was right 10 months ago and i was an F0 and now F2. Can you answer my question from my previous about your take on if i could have progressed that fast with labs the way they are, mostly normal??? thanks again

Thanks FL, your comment makes perfect sense :-)

[jmjm530]

Since you're elevating the discussion beyond Copy's individual interest, it's actually a lot more complicated than that because the preconditional biopsy was sprung on 'Copy' at the 11th hour as a result of a failure of communication with either his doctor and/or Dr. A's office. In any event, I do see your point but hope that Copy makes the decision based on whether or not he feels the biopsy is necessary for him.

-- Jim

[jmjm530]

Probably should add that I'm not exactly sure what I'd do in your position re having a biopsy or not. My logic would prob tell me I don't need one, but the rest of me might want one just to be double safe. Good luck with your decision.

-- Jim

[FlGuy]

I see your point and I recall the 11th hour stuff.  If I recall correctly (copy correct me) he could have seen A,  but without a fs or bx it would have been a waste (my opinion) of an important one time event.  Lots of tough decision with the disease and sometimes conflicting motives that drive us.

[copyman]

forgot, the waste of money comment by Dr A was for the CRS test, Dr A did put some weight on the F-sure test but did say it relied on one blood maker to much and sometimes can by off a stage. my take on the scan was that it is more accurate to tell if you have cirrhosis but maybe not that accurate determining lower stages?

[jmjm530]

I would go with Dr. A's take on the Fibrosure vs Fibroscan which I believe is that Fibroscan trumps Fibrosure in accuracy and you most probably would not have progressed that fast.

FL, I think what happened is that his doc told him he could get a scan with Dr. A, regardless, but it did not turn out that way. Yes, many conficts and tough decisions.

[cruelworld]

they automatically set me up in the cat scan room for mine. it was reassuring as i could see the picture of my insides on the monitor before they did it. it probably costs a lot more but i dont know for sure..i think total was about $3000, my cost after good insurance was about  $1500.

[copyman]

just a few more questions to ask you. you have me puzzled about the bx, i may be wrong but i thought you always were "pro" bx and suggested people to get them? so you are saying you may have relied on the fibroscan result if in my position? may i ask when you would treat if you were in my shoes? would you wait until F3. and last question, have you ever heard of someone progressing 2 stages in less then a year if they live right, no alcohol, etc.?

PS, i will get another F-sure soon.

[Forseegood]

I'm with Jim on this, though I don't have time to read the whole thread, if I were you, I wouldn't do a biopsy...you can average it out nicely from what you have had, and you've got low liver damage from what I remember (my memory can go in seconds! lol) unless youre doing a trial and they require one cause fibroscan hasn't been FDA approved yet, (and it will soon from what I've read) or there are indications that you have fatty liver (fibro can't measure that)  fibroscan has gotten mostly very good reviews from all I've seen...anyway, that's my two cents, and just my take, being no expert....(just to add, my own doc is a big fibroscan backer, and he's the head of the liver dept here at Cedar Sanai)

[sfwandwow]

my dr is doing by bx aug 31 iam kinda looking forward to it a little anxious but ready.. I hope it dont hurt..

[jmjm530]

As mentioned in my previous post, I'm not sure what I'd do in your position re the biopsy. My head would tell me probably not needed because of Fibroscan and Fibrosure results, but my penchant for wanting more information -- and the knowledge that I wouldn't treat until at least stage 3 -- might make me do the biospy. I'd say it would be 60-40 against me doing the biopsy given the existance of Fibroscan. As to when I would treat, yes, I would wait until F3, which I did not in a hypothetical, but in terms of my own treatment decision. In fact, I waited three years after my biopsy showed F3 which was mistankenly explained to me as between stage 3 and stage 4. Not that I'm recommending anyone wait that long. Maybe you're already mentione it, but what did Dr. A. have to say in terms of whether you should treat now or wait? Again, I'm with Dr. A in that your Fibrosure was probably off and your Fibrosis is not progressing that fast.

-- Jim

[Forseegood]

one more thing to consider, though saying it here prob won't go over really well, but I think in weighing decisions like these, it's good to factor everything in to make a good decision...there is a small risk in biopsy to consider as well, though very small...most everyone comes out okay, the vast majority...but there are a few who have had problems, a friend of mine had to get a vein cauterized, and they did it really fast and really well and he ended up fine, but I mean, this procedure isn't COMPLETELY without risk...if you've had both of these procedures I think it gives you a pretty good indication of where you are at, most patients aren't able to have the procedures you've already had to make a diagnosis of liver fibrosis...I'm just giving you some other facts to consider, of course if it makes sense to you and your docs, by all means do what you feel is best for your own satisfaction...

[copyman]

thanks for all the replies. is it possible to progress one or two stages in less then a year if labs are  normal for the most part? i would think & hope if someone was progressing that fast there would be some indication? thanks again

[Myown]

Dr A did put some weight on the F-sure test but did say it relied on one blood maker to much and sometimes can by off a stage.
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When I went to Dr.A, he told me that my "0" score from fibrosure test was more reliable than a bx. Told me I don't need a bx. Maybe if I was planning a bx and had the scan and the score of HIS scan came out different he would have given me the same answer as he gave you. Or possibly his opinion has changed since I saw him. A bx scares me because there is always risk, but a retired Hep doc told me that he did at least 1,000 or maybe he said 'THOUSANDS  -with an 'S' can't remember, but anyhow he said he never once ran into a problem.

As far as not getting a guided bx,,,,,, no way Jose. I don't care what anyone says- thats nuts. I wouldn't let someone cut my hair with a blindfold on even though they cut 100's of people and thats just hair - so why that I would ever let someone take one snip out of my LIVER with a blind fold so to speak??. My question to the doctor would be " okay you don't want to use an Ultra sound,,,,what if you were a doctor in Europe and you took 3 samples - would you then use an Ultra sound or depend only on your nose like a rescue dog or whatever method you use on people (other than your MOMMA  - she gets the guided I would GUESS)

Copy - do what YOU feel is best, really. Don't do something if you feel deep down that its not something you want to do. I just don't understand why a doctor wouldn't use an Ultra sound and if I was in your shoes and felt I had to get the ultra sound to feel comfortable, I would let the Radiologist do it.  As far as blood drawing or injections I feel a nurse does it much better. every doctor that ever stuck me with a needle hurt me - yet 99% of the times a nurse used a needle - I never felt it.So just because a Radiologist isn't the doctor doesn't mean he is not as good at doing the procedure. He may have done more than the doctor -who knows?

Either way I wish you the best and I hope you feel confident and peace in whatever you decide.

[FlGuy]

Radiologists are MD's.. My tx doc (a GI) is a master with the scopes.  He can do a light show with his scopes that would be the envy of the Hayden Planetarium and catch a fly with the tweezer attachement like a Jedi.  When it comes to the bx, both he and I know to go to guy with the expereince - the radiologist, in my area.

[Myown]

Radiologists are MD's..
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Well that shows how little I know. I thought they were just under the wire of being a doctor. Thanks for the info.

[jmjm530]

Copy: is it possible to progress one or two stages in less then a year if labs are  normal for the most part?
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I would go with Dr. A's opinion, which I believe is that given your stats and testing, that is not the case. Is it *possible* -- I guess anything is possible, but more likely that one or both of the tests were off a little -- and probably the Fibrosure. You didn't answer my question as to whether Dr. A. thought you should treat now or not?

MO: As far as blood drawing or injections I feel a nurse does it much better. every doctor
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The best injections I ever got were from a doctor but can't remember one every taking blood one way or another. There's a reason I go to Quest for blood draws -- as opposed to a NP -- and that's because in general they do a much better job for the simple reason that they draw blood all day long. I'm certainly not against guided biopsy's, but I say go with the most experienced person and let them do what they are comfortable with.

FL: When it comes to the bx, both he and I know to go to guy with the expereince - the radiologist, in my area.
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I think that is my point also. Go with the experience. Radiologist in your case.