Aa
Hepatology needs to enter the 21st Century ?
http://ihlpress.com/pdf%20files/hepdart09_presentations/liver/5_afdal_HepDart%202009%20Afdhal.pdf
Thought this is a very interesting presentation not to miss that is why posted it again on its own.
Bali05
Thought this is a very interesting presentation not to miss that is why posted it again on its own.
Bali05
trinity4: I don't believe Afdhal was making any argument for eliminating bx, as stated on his slide 32. Regardless of staging, bx provides information on inflammation/steatosis/iron etc. which is not readily available elsewhere. What he is saying, as I read it, is that the staging aspect of bx is so unreliable as to be misleading. Rather than pretend they can reliably differentiate in the 1.5 to 3.5 range, and follow progression over that span, pathologists should tell the truth : we can't.
Inability to stage is particularly relevant now because the next 5 years mark a major change in hcv management. By 2015, combo tx with r7128+bc/tv+ntz+soc (as needed) will cure nearly all in the developed world. So the question is, who can and can't wait until then?
mike : percutaneous is the standard needle bx shown on slide 4. Laparoscopic is more invasive : small holes are made and air is injected, along with a camera and tools. The surgeon gets to see what he's doing on the inside, can select where to draw a core, and can image the whole liver.
Agreed about the need to be wary of inexperienced FS operators - but I don't think that takes away from the technique when properly applied. Bali gives a very good approach - don't just look at the mean kPa, look at *all* the individual readings, their range and variability. (In fact, the inter-quartile range is usually reported in the summary). Readings like the ones cwar reported in another thread, which consistently vary up or down are suspect. A FS may not give you a reliable indicator of progression, but if properly run it's simply measuring the stiffness of your liver; for now it's unlikely anything else can do better.
yodennis: sorry things look grim. the humor around here may not be very good but I think you can safely assume no one's laughing at your expense. The 'insider' jokes just reflect the fact that most people are either still 'inside' or recently paroled.
Inability to stage is particularly relevant now because the next 5 years mark a major change in hcv management. By 2015, combo tx with r7128+bc/tv+ntz+soc (as needed) will cure nearly all in the developed world. So the question is, who can and can't wait until then?
mike : percutaneous is the standard needle bx shown on slide 4. Laparoscopic is more invasive : small holes are made and air is injected, along with a camera and tools. The surgeon gets to see what he's doing on the inside, can select where to draw a core, and can image the whole liver.
Agreed about the need to be wary of inexperienced FS operators - but I don't think that takes away from the technique when properly applied. Bali gives a very good approach - don't just look at the mean kPa, look at *all* the individual readings, their range and variability. (In fact, the inter-quartile range is usually reported in the summary). Readings like the ones cwar reported in another thread, which consistently vary up or down are suspect. A FS may not give you a reliable indicator of progression, but if properly run it's simply measuring the stiffness of your liver; for now it's unlikely anything else can do better.
yodennis: sorry things look grim. the humor around here may not be very good but I think you can safely assume no one's laughing at your expense. The 'insider' jokes just reflect the fact that most people are either still 'inside' or recently paroled.
When I was diagnosed with cirrhosis I went into a bit of a funk, no doubt about it. But then I decided I could either yeild to the disease, or live my life on my terms. I wanted to enjoy every day with my young son, and so I chose the latter. Ultimately, I did reach SVR, and of course that took some of the heat off.
But I still have cirrhosis. If it's going to cut my life short so be it. But I have control over whether it's going to muck-up the time I have between now and then.
Your mileage may vary, and I don't mean to preach. But this is my perspective, FWIW.
But I still have cirrhosis. If it's going to cut my life short so be it. But I have control over whether it's going to muck-up the time I have between now and then.
Your mileage may vary, and I don't mean to preach. But this is my perspective, FWIW.
You know sales pitch or not - big pharma or not - thank God every day that people are out there developing the new miracle drugs we've been reading about. Profit and stocks drive the world but whatever they are doing to try and further the cause of annhiliating this disease..........good for them.
All the fibroscans and tests mean nothing if you don't take the medicine to go along with the obsessive testing. Even Peg_IFN can be considered a new miracle drug - ten years ago what were the odds you would beat this without the combo?
I don't care who they are bring on the new drugs and better cure rates! The rest is a moot point.
All the fibroscans and tests mean nothing if you don't take the medicine to go along with the obsessive testing. Even Peg_IFN can be considered a new miracle drug - ten years ago what were the odds you would beat this without the combo?
I don't care who they are bring on the new drugs and better cure rates! The rest is a moot point.
just faxed the fibroscan report from 8/20/09 in Germany result 8.0 kPa=F2-F3
to the doctor that gave me fibroscan 5.9 kPa = F1 on friday.
Just because it was a good result does not mean I am not questioning it
but F1 is on the other end of the spectrum and FibroScan is pretty accurate
with F0-F1 or F4.
Will see if need be I will repeat it to absolutely exclude any error.
However the Dr. who did FibroScan spends most of the week
on liver transplants ,so I kind of feel confident he knows how to get to my liver.
I am also skinny so my liver is very easy to locate and probe.
Happy to have FibroScan in town that`s for sure.
to the doctor that gave me fibroscan 5.9 kPa = F1 on friday.
Just because it was a good result does not mean I am not questioning it
but F1 is on the other end of the spectrum and FibroScan is pretty accurate
with F0-F1 or F4.
Will see if need be I will repeat it to absolutely exclude any error.
However the Dr. who did FibroScan spends most of the week
on liver transplants ,so I kind of feel confident he knows how to get to my liver.
I am also skinny so my liver is very easy to locate and probe.
Happy to have FibroScan in town that`s for sure.
Yes Mike they did. It showed no iron accumlation at the time of biopsy which was in the latter part of 07 and my ferritin level at the time was near 1000. It was the Porphyria Cutanea Tarda that was causing the elevated ferritin which was resolved with phlebotomy but my hgb was 17 at the time which is high for a woman. The biopsy also ruled out hemochromatosis.
Even though I didn't SVR, since phlebotomy and completing treatment, my hgb levels are normal and the PCT hasn't come returned.
Even though I didn't SVR, since phlebotomy and completing treatment, my hgb levels are normal and the PCT hasn't come returned.
Hi, Trin. Did the Mayo Clinic stain for iron on one of your biopsy slides? Is that how you found out there was iron accumulation in your liver? (Just want to get this straight.)
M.
M.
Hi, Trish. Well, you´re right, of course, when you say that cirrhosis is not the only thing that it´s important to diagnose. The progression is equally or more important. I tried to make that point, but maybe failed. What I meant was that it´s all really about avoiding cirrhosis, the tests and treatment. While we just have fibrosis and not yet cirrhosis, we have intact livere function. Although I think I read that even fibrosis can cause liver cancer.
As for my criticisms of biopsy, my point was that, not only isn´t it reliable vis-a-vis the whole liver, but for rapid progressors waiting three years is too long. I have talked my hospital into doing me another biopsy 2 1/2 years after the first one, but that is unusual. And if it turns out that my fibrosis has progressed to F4, what good was the test? What we need is accurate staging of the whole liver (or a mean score for it obtained by sampling) that is not invasive. This we do not yet have. Fibroscan is not the answer. Neither are any of the other tests.
Personally, after having undergone most of the different tests, I believe that the answer will come from a form of FibroTC (see my images for FibroTC results using tomographic imagery) using not gamma (x-) rays but MRI. FibroTC is just an analysis of the data; but the data must be taken from the entire liver, as it has now been shown convincingly that HCV-caused fibrosis is not necessarily homogeneous throughout the liver.
Mike
As for my criticisms of biopsy, my point was that, not only isn´t it reliable vis-a-vis the whole liver, but for rapid progressors waiting three years is too long. I have talked my hospital into doing me another biopsy 2 1/2 years after the first one, but that is unusual. And if it turns out that my fibrosis has progressed to F4, what good was the test? What we need is accurate staging of the whole liver (or a mean score for it obtained by sampling) that is not invasive. This we do not yet have. Fibroscan is not the answer. Neither are any of the other tests.
Personally, after having undergone most of the different tests, I believe that the answer will come from a form of FibroTC (see my images for FibroTC results using tomographic imagery) using not gamma (x-) rays but MRI. FibroTC is just an analysis of the data; but the data must be taken from the entire liver, as it has now been shown convincingly that HCV-caused fibrosis is not necessarily homogeneous throughout the liver.
Mike
Great links, especially the IHLPress one! Thanks.
FWIW, I had a very instructive experience with Fibroscan last year. It´s all detailed in my initial post at the thread "Fibroscan ad libidum; or, Who controls the controls?" (http://www.medhelp.org/posts/Hepatitis-C/Fibroscan-ad-libidum-or--Who-controls-the-controls-/show/1113657). I´m not blowing my own horn here, just trying to provide information.
My conclusion re Fibroscan was this: In the hands of an experienced operator with good technique (like using an ultrasound scan to position and trigger the Fibroscan pulse), it may be a good test for differentiating between early-stage fibrosis and cirrhosis. It is NOT a good way of following fibrosis progression from stage to stage (F0 - F4).
This is what most of the impartial reports say, and my experience bears them out.
(BTW, willing, can you tell me what the difference is between a percutaneous biopsy and a laparoscopic one, that is, which is better and why? I´ll be doing a new biopsy in about six months and have a choice.)
Mike
FWIW, I had a very instructive experience with Fibroscan last year. It´s all detailed in my initial post at the thread "Fibroscan ad libidum; or, Who controls the controls?" (http://www.medhelp.org/posts/Hepatitis-C/Fibroscan-ad-libidum-or--Who-controls-the-controls-/show/1113657). I´m not blowing my own horn here, just trying to provide information.
My conclusion re Fibroscan was this: In the hands of an experienced operator with good technique (like using an ultrasound scan to position and trigger the Fibroscan pulse), it may be a good test for differentiating between early-stage fibrosis and cirrhosis. It is NOT a good way of following fibrosis progression from stage to stage (F0 - F4).
This is what most of the impartial reports say, and my experience bears them out.
(BTW, willing, can you tell me what the difference is between a percutaneous biopsy and a laparoscopic one, that is, which is better and why? I´ll be doing a new biopsy in about six months and have a choice.)
Mike
I appreciate the absence of defensiveness and the consideration. And I'm really not trying to create a distracting metadiscussion on humor other than to say some of the humor some of the time feels indulgent and irrelevant and kind of "insiderish". While I would feel this way philosophically under any life circumstances, having cirrhosis myself makes it personal. Living with a question mark *****. Counting down your life in years or months rather than decades *****. Having your liver be a picnic for the Hep C virus *****: No joke. d
I've made a joke myself on the topic of biopsy/autopsy.
I've said that autopsy is the "gold standard", meaning the best that there is.
We often hear that a biopsy is the gold standard, but in reality, in addition to being invasive and in the rare occasion, even being fatal, they at times do not accurately reflect the actual condition of the liver. This can be for a variety of reasons; ranging condition of the liver where sample are taken (all livers are not homogeneous, staging wise throughout), the varying of sizes of sample, the number of samples used, and the actual range of interpretation by the people evaluating the actual sample.
Bill was making a similar joke, the point being that a biopsy lacks the amount of information needed to completely make a correct assessment. A tiny plug of liver pulled from a biopsy needle just doesn't compare. (However) A biopsy still remains the best *single* tool for assessment that we have available to us to plot our course.
My own belief is that the combination of tests gives the best sense of where we sit; our labs, an annual fibrosure test and a liver biopsy every so often depending on our staging and other risks and of course any other tests recommended by our medical team and circumstances.
Anyway, Bill's comment was taken by me for humor and in no way to be hurtful.
My 2 cents.
Willy
I've said that autopsy is the "gold standard", meaning the best that there is.
We often hear that a biopsy is the gold standard, but in reality, in addition to being invasive and in the rare occasion, even being fatal, they at times do not accurately reflect the actual condition of the liver. This can be for a variety of reasons; ranging condition of the liver where sample are taken (all livers are not homogeneous, staging wise throughout), the varying of sizes of sample, the number of samples used, and the actual range of interpretation by the people evaluating the actual sample.
Bill was making a similar joke, the point being that a biopsy lacks the amount of information needed to completely make a correct assessment. A tiny plug of liver pulled from a biopsy needle just doesn't compare. (However) A biopsy still remains the best *single* tool for assessment that we have available to us to plot our course.
My own belief is that the combination of tests gives the best sense of where we sit; our labs, an annual fibrosure test and a liver biopsy every so often depending on our staging and other risks and of course any other tests recommended by our medical team and circumstances.
Anyway, Bill's comment was taken by me for humor and in no way to be hurtful.
My 2 cents.
Willy
It was necessary to see if the liver was experiencing iron overload which will cause more damage.
Let me phrase this differently because of course there was iron overload in my blood and liver. What I should have said was the biopsy determined if iron had accumulated in my liver thus causing more problems with additional damage and increasing the percentages for cirrhosis and liver cancer.
Let me phrase this differently because of course there was iron overload in my blood and liver. What I should have said was the biopsy determined if iron had accumulated in my liver thus causing more problems with additional damage and increasing the percentages for cirrhosis and liver cancer.
Biopsy was the most effective tool I could have used to determine the health of my liver. Having PCT, in was necessary to see if the liver was experiencing iron overload which will cause more damage. Ferritin tests cannot tell you whether the liver has been affected or not. In my case, no iron overload yet and biopsy which was sent to the Mayo Clinic determined stage 3/4. Two samples were sent and I got the most accurate diagnosis available so I did not have to fret about whether treatment was necessary or pit it against any other test. No other test could have given me as detailed a diagnosis of my liver stage as my biopsy did and I did not incur additional costs trying to make an intelligent decision about treatment.
I maintain liver biopsy is still the gold standard and especially when there are any other factors involved.
Trinity
I maintain liver biopsy is still the gold standard and especially when there are any other factors involved.
Trinity
With hindsight, I realize my comment above might have been off color and probably unnecessary. If I caused you or anyone else discomfort or grief, you have my apologies… we have enough to worry about without that.
Take care, and good luck--
Bill
Take care, and good luck--
Bill
Mike716: "biopsy a little better but you have to wait years for a second one to show any relaible changes, and it (biopsy) is just as observer-sensitive as Fibroscan.
In other words, as yet there is no trustworthy test for fibrosis staging.
However, the article's conclusion (the only thing that means anything is whether or not you've got cirrosis) begs the issue. There is a crying need for a test that reliably shows fibrosis progression, the only way to guage how far off cirrosis is."
Well - it only takes years for a second one to show any reliable indicator of changes because it often takes years for their to BE any changes and there may be none. It's not that the biopsy is incapable of showing them. If you get a biopsy in a few years after the last one and the results are the same, then it's likely that your progression has remained stable.
I'd beg to differ that the only thing that means anything is whether you have cirrhosis. It's important to avoid cirrhosis if possible as your treatment options and outcomes certainly reduce at that point. I certainly wasn't going to wait until cirrhosis and being a Grade 1, I would have done biopsies not more than 3 years apart to gauge how I was doing if I was going to wait out treatment for more effective therapies. So readings of Stage 2 or Stage 3 would have mattered a great deal along the way also and I'm sure would to a great many, as evidence of the progression and addressing the question of can you still afford to wait.
While we might want more reliable tests, the conclusion is useful when discussing cirrhosis in that he's saying use all the diagnostic tools together to determine the reality of the situation. Prior to cirrhosis, it seems that biopsy is still the most reliable thing we have and still has a role to play in providing supporting information to make good decisions regarding treatment decisions.
In other words, as yet there is no trustworthy test for fibrosis staging.
However, the article's conclusion (the only thing that means anything is whether or not you've got cirrosis) begs the issue. There is a crying need for a test that reliably shows fibrosis progression, the only way to guage how far off cirrosis is."
Well - it only takes years for a second one to show any reliable indicator of changes because it often takes years for their to BE any changes and there may be none. It's not that the biopsy is incapable of showing them. If you get a biopsy in a few years after the last one and the results are the same, then it's likely that your progression has remained stable.
I'd beg to differ that the only thing that means anything is whether you have cirrhosis. It's important to avoid cirrhosis if possible as your treatment options and outcomes certainly reduce at that point. I certainly wasn't going to wait until cirrhosis and being a Grade 1, I would have done biopsies not more than 3 years apart to gauge how I was doing if I was going to wait out treatment for more effective therapies. So readings of Stage 2 or Stage 3 would have mattered a great deal along the way also and I'm sure would to a great many, as evidence of the progression and addressing the question of can you still afford to wait.
While we might want more reliable tests, the conclusion is useful when discussing cirrhosis in that he's saying use all the diagnostic tools together to determine the reality of the situation. Prior to cirrhosis, it seems that biopsy is still the most reliable thing we have and still has a role to play in providing supporting information to make good decisions regarding treatment decisions.
yodennis: sorry if you feel offended, but if it wasn't for gallows humor, whether it's autopsies or ED, there wouldn't be much humor at all around here ... anyway, apart from the joke, Bill's point is true - nothing short of autopsy is going to give you a definitive fibrosis reading
all: given that we have to live with approximations, I think Afdhal's presentation is a good one for everyone trying to sort out how much liver time (Tm dointime) they have left.
The conference presentation is from last Dec. and the article with the results of that two-phase FS study is probably in press somewhere. The US is way behind the rest of the world in FS use (which is why you usually have to leave the country for one) but the advantage of being last is that there's more to compare with.
As I read it, Afdhal's point is not that FS is unreliable - in fact the opposite. Coefficient of variation, is 4 to 5 % (slide 21) whereas for biopsies 33% show variation of 1 stage or more (slide 7). So the fundamental problem is that the "gold standard" is only gold-plated, if that. The precise assessment of how far fibrosis has progressed is an unreachable goal (short of autopsy of course..). With all the available tools (markers: platelets/INR/bilirubin/Alk. Phosphatase/etc.; FS; bx; US of spleen diameter and portal vein; etc. etc. ) the best we can do is with any reliability is three-stage triage: OK, advancing-advanced, and cirrhosis.
Since '93 I've had three percutaneous bxs, one laparoscopic, two FS and one fibrosure. Sent the slides around to multiple pathologists for 2nd opinions. What have I learned? nothing - I'm still somewhere in the great middle, progressing, with no clear sense of how much time is left other than that there's less of it.
On the other hand, as cirrhosis hits, multiple indicators tend to click in concurrently - stealth cirrhosis is not a worry. Afdhal is about as good they get, it's worth looking at what he has to say.
all: given that we have to live with approximations, I think Afdhal's presentation is a good one for everyone trying to sort out how much liver time (Tm dointime) they have left.
The conference presentation is from last Dec. and the article with the results of that two-phase FS study is probably in press somewhere. The US is way behind the rest of the world in FS use (which is why you usually have to leave the country for one) but the advantage of being last is that there's more to compare with.
As I read it, Afdhal's point is not that FS is unreliable - in fact the opposite. Coefficient of variation, is 4 to 5 % (slide 21) whereas for biopsies 33% show variation of 1 stage or more (slide 7). So the fundamental problem is that the "gold standard" is only gold-plated, if that. The precise assessment of how far fibrosis has progressed is an unreachable goal (short of autopsy of course..). With all the available tools (markers: platelets/INR/bilirubin/Alk. Phosphatase/etc.; FS; bx; US of spleen diameter and portal vein; etc. etc. ) the best we can do is with any reliability is three-stage triage: OK, advancing-advanced, and cirrhosis.
Since '93 I've had three percutaneous bxs, one laparoscopic, two FS and one fibrosure. Sent the slides around to multiple pathologists for 2nd opinions. What have I learned? nothing - I'm still somewhere in the great middle, progressing, with no clear sense of how much time is left other than that there's less of it.
On the other hand, as cirrhosis hits, multiple indicators tend to click in concurrently - stealth cirrhosis is not a worry. Afdhal is about as good they get, it's worth looking at what he has to say.
Man that autopsy joke reads caustic to me! Rather than trying to impress with sarcasm (which in this case feels superfluous) why not consider the feelings of those with cirrhosis that cannot be defeated with current therapies and have to look their children in the eyes each day. d
here is another one also from willing
ton of great stuff , have not gotten to read it all but the titles looks
great
http://ihlpress.com/gaj_hepdart2009.html
you got to thank willing for it
ton of great stuff , have not gotten to read it all but the titles looks
great
http://ihlpress.com/gaj_hepdart2009.html
you got to thank willing for it
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