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No Fibroscan - Jim Help

Coordinator from St. Louis called back. Trial is in a different stage nationwide, now requiring biopsy within 6 weeks. Insurance won't pay.

I did go pick up records from my last office visit (Feb. 07) so here goes. Jim read between the lines for me: NP notes read:

At a previous appointment it was clarified that she had progressed to cirrhosis. Original biopsy found stage 2 changes but in light of a low platelet count, there was a suspicion for more advanced liver disease. CT of the abdoment found evidence of portal collateral systemic changes that confirm cirrhosis. The patient has well-compensated disease and strong hepatic synthesis. (Original July 06 CT report said: cirrhotic-appearing liver. 0.9 low dense lesion in right hepatic lobe. No definite enhancing lesions identifified. Portal vein is patent. Negative spleen. A few borderline prominent upper quadrant lymph nodes.) How did he get confirm out of that?

He checked for HCC at this visit. Ultrasound: A cirrhotic liver is demonstrated. Spleen bordline enlarged at 12 cm. No ascites, no neoplasm noted. AFP: result 5 ng/ml (range 0-6) (Keep in mind the Ultrasound tech started with the idea I was cirrhotic.)

Fast forward to May 5, 07. The trial I was trying to get into has my doctor in charge of it (I never see him, though, just the NP). For whatever reason, my Doctor looked me in the eye at "go time" in the trial coordinator's office (796) and after having my July 06 biopsy re-read, he says to me, your biopsy is a 2-1. I started to protest, because I was stunned to hear this, blurting out "What about all the other tests?" He almost cut me off, saying the biopsy is the gold standard. I said "In that case I am waiting to treat and beat it out of there. I took the summer off! Only checked in here once and while and didn't worry. But in the back of my mind...

Here are my thoughts:

Maybe he was actually trying to help me get in to the trial by leaving out results other than biopsy and was wishing I would shut up and not tip off the coordinator. Don't ask, don't tell.

He didn't look at my file first.

He is right. Just because it is cirrhotic-appearing and what does "is demonstrated mean? Maybe he thinks the other guys made a mistake?

There it is. Sorry it is so long?  Just like everyone else, II only want to do this one time!
39 Responses
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Avatar universal
Well, one could only hope :)
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Avatar universal
MEDICAL PROFESSIONAL
Unexpected early snowfall could hamper the return of the livermobile to save Californian grounds. Not to mention the trail of desperate/surprised NAFDL cirrhotics fallen out of the clouds of save prosperity.
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Avatar universal
Are you planning on coming East by "LiverMobile" or by air :)
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Avatar universal
MEDICAL PROFESSIONAL
i expect it to be approved in 2008, but the Echosens people will know more about this. i will meet them in Boston.
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Avatar universal
echosens is a very good company. a while back i emailed them and asked when the fibroscan would be approved for use in the USA and they responded right away that it looks like the 1st qtr of 2008. can you confirm this? do you see it available for next year?
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Avatar universal
MEDICAL PROFESSIONAL
hi, always a pleasure to meet you.BTW The www.echosens.com website of the French company gives alot of info re the fibroscan.

But to answer your questions re the physics of the fibroscan precedure :
A hand held probe is used that is both the actuator of the low frequency mechanical shearwave that can, surpisingly, be generated in a semiflabby material like the liver. The same probe also send the high frequency ultrasound pulses that " follows" this mechanical shearwave as it propagates through the liver. But no it is not a resonance phenomen with the ultrasound at all, but a low frequency ( 5o Hertz) mechanical push that starts the wave - a single wave, ideally- from the surface of the liver.  A mathematical/physics paper has been published by Laurent Sandrin, the French physicist/mathematicien who invented the basic principle. He had an interest in the elastic properties of semisolid matrials, this was kind of an offspin.We had many discussions re the optimized use of the fibroscan.
Now as this wave, started by a momentary brief mechanical probe hit on the surface, propagates inside the liver, the ultrasound probe that is build into the same tip, will send a rapid US pulse that will give ( show you a density, that is translated into color) you a density plot at the liver in this approx 8mm diameter  investigative cylinder at this very ultrabrief moment, which will be continuosly displayed parallel to the y axis of the eventual "wave picture". Here comes the key element to understand : Before and after the actual wave front  there is a zone of elevated and reduced density that the ultrasound will record and show in say a 1mm strip parallel to the y axis.
Then comes the next US pulse, finds the wavefront has moved on a bit and records the next 1mm strip to the right of the previous one, not erasing but adding to the previous one. This is done over and over again, while the wave moves, generating the total depth (yaxis) vs time(x-axis) plot of the wavefront movement. This way the dynamic movement of an elastic wave has been "frozen" into a true twodimensional  distance vs time plote of the wave penetration - reflecting with extreme accuracy its actual propagation speed.

And yes, the liver is elastic enough to allow a local distortion at the right frequency to propagate, through both frontal and lateral oscillations- through the liver in a forward moving wavefront generating mode with zones of increased density due to elastic tissue compression - yes like a spring- at and behind this wavefront. In a good shot, an astonishing elegant wave can be generated, clean and beautiful with the possibility to determine its speed with high precision from the ultrasound density/time graphing.  You basically see two parallel lines running inwards and sidewards, with the slant being a measure of propagation speed.
There is something very, very important to note about this graph: It only records depth of wavefront and time : both can be measured with highest accuracy and do not need extra sophisticated calibrators ( like a "standard liver") that you have to hit from time to see that your fibroscan machine is still accurate.NO, distance and time is all thats really measured and that is inherently accurate with such a device.

But as described above interfering secondary waves can easily be generated from vibrations that result from the probe also hitting the ribs which then send a second, third etc vibration down the liver, leading to confusing, scattered pictures, that the computer scrambles to interpret, or there is too much fat between the probe tip and the liver so the wave is not started properly.

From the wave speed to the Kilopascal value -there is just one physics formula that converts the speed into Kpascal, expressing its hardness. One could have used the speed itself.
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Avatar universal
It's really good to see you here again, we all really appreciate your input when you have the good graces to provide it to us. I read your post above about the mechanics of the fibroscan, something I know very little about. And although your response is very complicated, I get the gist that the fibroscan is a machine that uses some sort of hand held probe. And this probe is run over the belly of the patient being scanned (similar to an ultrasound?). And this probe produces ultrasonic (or simply "sonic"?) pulses which propagate through the tissues and into the liver. The liver is then stimulated, or "jostled" by the excitative energy provided by the handheld probe. Is that an accurate description? And once the liver is "jostled" (at whatever frequency is used) the probe also has a sensor of some type that is capable of receiving the reflective pulse(s) that come from the now oscillating liver. My sense is that the whole system is trying to determine the liver's various resonate frequencies. You make many allusions to the stiffness and the importance of measuring it, which to me strongly smacks of an ordinary mass-spring system. Is that what's going on here? Are you stimulating the liver with a sweeping variety of amplitudes and frequencies in a variety of locations in an attempt to discern the average natural frequency of this complex, 3D gelatinous blob of flesh?  If so, is that what all of this is boiling down to? The ole' natural frequency (usually denoted with omega) is equal to the square root of k/m with k being (spring) stiffness and m being the mass of the liver? I know it can't possibly be quite that simple being that the liver is a complex three dimensional organ with undoubtably heterogeneous features (with correspondingly heterogeneous stiffnesses throughout its volume). I suspect there's a bunch of fancy polynomials and diff eqs that are necessary to model the  measured feedback amps/freqs. But it would sorta make sense that that's the bottom line here. From my layman's understanding an advanced cirrhotic's liver can be as hard as a rock, which would obviously imply a high stiffness and a correspondingly high natural frequency. A healthy liver is soft, compliant and highly elastic (with low stiffness) which would obviously imply a low overall average natural frequency. So the lower the overall natural frequency of the liver, the lower the stiffness and therefore the less fibrosis there is?? And conversely the higher the natural frequency the more stiffness there is and the more fibrosis there is?? Do I have that even remotely right? Or is it more of a direct assessment made through some kind of force-displacement measurement??

It sounds so teasingly familiar, and yet at the same time it seems cryptic and alien. But ultimately it always comes down to the basics, no matter how complicated it seems in the endgame. I just hope I've come close to touching on what's going on here. Either way, thanks again for you input, VERY interesting!
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Avatar universal
Probably should add that the pathologist who looked at my biopsy prior to me treating, noted my stage as 3/4. I was mistakenly under the impression from my first doctor that this meant I was between stage 3 and 4. Later, I found out that it meant I was stage 3 out of 4 stages. And during tx learned that indeed I might even be closer to stage 2. Given this experience, I think everyone should make sure they understand exactly what their biopsy report means and getting a second pathologist to read the slides is also quite reasonable, especially when in the mid-range.

-- Jim
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Avatar universal
Got cut off because of the script charaters used. I'll try again with different notation..

KPA less than 7.5 would be stage 0 or stage 1.
KPA 7.5 to 9.5 would be stage 2
KPA 9.5 to 12.5 (or 14) would be stage 3

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Avatar universal
I see HR put your 8.8 between stage 1 and 2. I was under the impression that my 8 put me at low 2. Here are some numbers I jotted down I think from the tech guy although the doc seemed to be more optimistic with them. Of course I may have jotted them down wrong, which is very possible considering all the drugs in my system at the time :)

kpa 9.5 -12.5 (or 14) -- stage 3
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Avatar universal
I just noticed on the Fibroscan report that there was a checkmark indicating that 8 measurements were able to be obtained to compute the Median. Also, in those cases where 8 measurements could not be achieved, there was a space to check the reasons such as: Abdominal Wall Fat; Anterior Liver Positioning; Narrowed Intercostal Space;
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Avatar universal
Yes, I know. Actually was on Lipitor for a month or so and got my LDL below 100. Then stopped to see if some fatigue and muscle soreness was Lipitor related. Inconclusive, but I think probably not. Plan on starting up again soon, but thinking of Red Rice Yeast Extract instead of Lipitor. Any opnions on this?

Copy,

Mid treatment kpa 9.5 (high two, borderline 3)
A few months post treatment kpa 8.0 (low 2)
Last biopsy was close to three years prior to treating. Interpretation of those slides varied from stage 2 to stage 3.
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Avatar universal
not sure if you ever posted it but what was your "post" tx fibroscan kpa result? hope you dont mind me asking. thanks
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Avatar universal
MEDICAL PROFESSIONAL
Your fibroscan results places you between fibrosis stage one and two. Good Interquartile range = low variability between accepted shots. Results probably reliable. In the future the actual images should be handed to the patient, so he can show them to another expert  on this technique to get a more educated judgement. Just like having a copy of your biopsy slides.

Jim - you see ( above) copy  got the median - not the mean, which is the worldwide technique used.
BTW the kilopascal refers to the pressure rquired to stretch an elastic material to 200% called the elastic module or Youngs module. If a material is very stiff or hard, then a higher force is necessary to stretch it that much, so it is a measure of the inherent stiffness of any material, in this case the liver.
Jim, I would certainly agree that you have no real need to redo a fibroscan at this point. Provided you do not have a strong propensity towards NAFLD, which is somewhat linked to metabolic syndrome.  An advanced lipid profile using NMR from Liposcience is a much more urgent priority.AND the VAP lipid profile from Labcorp AND a coronary artery scan using Electron Beam Tomography. That will either relieve you or focus you on what might really matter now...All very accessible.
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Avatar universal
IMHO, I would have trouble knowing what to believe with your results also. There is over a 30% sampling error in biopsies so it is possible to get a better or a worse biopsy score than you actually have. That is one of the reasons serial biopsies are good over time. Also depending on your doc's experiences and the fibroscan and markers in the blood, physicians make an educated guess. Remember medicine is an art as well as a science.  Good luck with your decision making process.
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Avatar universal
Yikes! Should have re-read my comments before I hit post. But then we wouldn't be having such a good laugh.  : )

Good one Shecky530!
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Avatar universal
Foo: Hopefully I am anatomically correct! I will check with Foresee to get more details.
------------------------------------------------------------------------------------------
If "Forsee" is busy, I'd be happy to check on the 'anatomically correct' part :)
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Avatar universal
HR: maybe you are now just scratching the surface of the 95% intervall for stage 3 fibrosis.
-----------------
I can't say I now have a full understanding of the entire process/differences between the two scan techniques, but given the limitations of this forum, your answer was very helpful.

As to the above quote, I'm guessing you are referring to my three year old biopsy results, as opposed to the two scan results? The pathologist who staged it at 2.5 actually took the time to show me the slides in his office and explain why it wasn't exactly a two or a three. What I'd like to think is that now I'm closer to a stage 2 (or even better) based on my second Fibroscan post treatment.

If I had a "need to know" I'd be at your office in a heart beat, assuming you'd see me. However, right now, I'm more comfortable avoiding tests, doctors, and procedures, at least for the time being. Just too much of all the aforementioned during the past few years :)

Thanks again for all your help.

Be well,

-- Jim
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Avatar universal
Thanks so much for stopping by and for your explanation of the scan. It was music to my ears. As everyone here, I just want to make as informed a decision as possible.. I think it is absolutely something that could help me to do so.

Hopefully I am anatomically correct! I will check with Foresee to get more details.
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Avatar universal
MEDICAL PROFESSIONAL
Each "shot" of the fibroscan probe gives you a wave propagation pattern that ideally is smooth and reflects only one "clean' wave that propagates through the liver and is followed by rapid ultrasound pulses that identify zones of higher density that the elastic wave generates as it travels through the liver. This is one dimension of the two dimensional plot that is generated for each shot, the second one is time. Therefore the angle of this density pattern is ideally the propagation speed of the elastic wave. There is a direct formula between  (the tangens of) that angle and the elastic module of the material, expressed in Kilopascal. That is a fixed formula, nothing to manipulate or judge. What is open for interpretation is whether the wave is clean and smooth enough or contains artefacts. The " algorithm" is not the relation between the liver stiffness and the fibrosis stage, but at this point in the process it is an imaging processing program that "looks " at the picture of the individual shot and determines A: Is there a clean wave or too many artifactual secondary scatterwaves? B; If the machine algorithm accepts the individual picture as worth evaluating, it then "measures" the above mentioned angle or slant and prints/overlays the results of its interpolation/calculation on top of the twodimensional picture. The human eye and brain can see if  A: a picture was accepted that was too scattered/artefactual and or B: that the superimposed "slant line" was yes or not not placed correctly on the true elastic wave that can be seen. Ideally the operator can agree with the machines "acceptance decisions and placements" and then everything is according to "protocol". Now you have to trust me that a humans image processing capacity are still vastly superior to that of such a software and as such improper machine acceptances should be discarded. If you dont, your results will simply wobble much more around the true elasticity, which is all we are trying to measure. The placement in one of the "F" categories is simply done by overlaying the patients Kilopascal results on the frequency distribution of the trial results that link the two methods together. There is no computer algorith involved here and no more protocol. If the reference intervals should be slightly adjusted from time to time (like to the "American population") it does not mean that your fibroscan elasticity measurements have changed - maybe you are now just scratching the surface of the 95% intervall for stage 3 fibrosis.
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Avatar universal
MEDICAL PROFESSIONAL
When several pieces of information come together, like in your sons case, it is likely that he has cirrhosis that has led to one of its major complications :ie  portal hyprtension.  The term cirrhosis is broad and complex and the functional consequences of intense fibrosis are severalfold :
1. Restriction of portal blood flow, leading to higher than normal pressure in all of the portal vein connected blood vessels, with the tendency of the body to develop collateral ways to remove the blood from the portal system, therefore esophageal and gastric varices, in the spleen the extra venous pressure can lead to enlargement.
2. The synthetic capacity of the liver can be reduced due to a reduced mass of functional hepatocytes. (Albumin, clotting factors, prothrombin time etc). Also some factor stimulating platelet synthesis is produced in lesser quantity, so, together with enhanced splenic activity, platelet numbers move downwards.
3. In cirhosis/intense fibrosis the intimate exchange between the portal blood and the hepatocytes can be reduced so the processing and cleaning -detoxifying and metabolic functions of the liver deccrease, because the space of Disse is filled with fibers now precluding proper contact and diffusion of the portal blood to the processing hepatocytes. The processing of intestinal ammonia into nontoxic urea is one example of the livers detoxifying  capacities that slowly fail, leading to accumulation in the systemic circulation with subclinical and manifest hepatic encephalopathy. Thats why your son is on lactulose, to counteract the ammonia production and more.


The clinician is in the difficult position to estimate the overall situation of the three components of declining liver structure/function from a limited set of parameters. Thus overall the term cirrhosis can mean many substages and subfunctioon declines that can only be estimated. Everything in the diagnostic armamentarium needs to be put together to come up wit the best possible estimation.

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Avatar universal
glad to see you had a chance to stop back :-) i had a question about a fibroscan i had in Aug in boston. wanted your opinion on the results and what stage you would have put me at. the reason i ask is the person that did the scan was very young and i had a feeling they had not done many before. i had a biopsy about 6 weeks later that had me stage 1 grade 1. here is the exact measurement from the fibroscan form:

median fibroscan measurement 8.8 kpa
IQR 1.1 kpa
number of attempts 11
number of measurements obtained 9
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Avatar universal
Elaine's (child24angel) 24-year old son, Nick has hemophelia and is a 3X non-responder with apparent cirrhosis. If you think your expertise could be helpful, it would be great if the two of you could get together in some capacity.
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Avatar universal
Forgot to ask, re your protocol. Since your're not using computer alogorithms to correlate scan results with biopsy stages -- how do you determine then if someone is a stage 2 as opposed to a stage 3? Is this something you can "see" like a pathologist sees under a microscope? If so, then this is a radically different approach from the scan protocol where I don't believe the operator "sees" anything, although I could be wrong on that.

But if you do actually see fibrotic tissue/bridging, etc -- then the type of "double" report I mentioned could be very useful, in spite of bringing operator bias/error back into the equation as we now have with needle biopsy.

As a personal example, I had the same biopsy slide set read by four different pathologists, all supposedly excellent, at four  different hospitals, including the scan center's pathologist. I was staged at: 3, 2, 2.5 and 3. Pathologist bias therefore was a full stage. My scan put me somewhere between stage 2 and 3  and was taken three years after the biopsy mid treatment. A second scan put me closer to stage 2 and was taken I think four months after I stopped treating.
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