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Type of Biopsy
I have seen this question asked many times and have written answers expressing my support of laproscopic biopies in the past. After this last needle core biopsy I want to change my opinion and give reasons. I would be interested in what others have to say.
I pulled all 3 of my biopsy reports and read them and compared them. I had 2 laproscopic and 1 needle core, and have decided we need to get the needle core. For my first biopsy (2005) the GI said who do you want to do this biopsy - a radiologist or a surgeon. I thought that was a no brainer - surgeon. They come in from around the naval with a laproscopic camera and follow with the knife that cuts little wedges. These are necessarily done on the bottom side of the liver. Report showed grade 1, stage 1-2
The second biopsy (12/2007) was ordered by a hepatologist. I had already contacted the (same) surgeon for a laproscopic, but the hepo told the surgeon he wanted cores so the surgeon took wedges and cores. Looking back at the pathologist's report (the hepatologist's pathologist) he was not at all pleased with the samples. Of the wedges, he says, "there is a suggestion of periportal fibrosis, but this is difficult to evaluate because of the subcapsular nature of the biopsy specimen." -- meaning that the specimen was (.6x.6x.3) too close to the edge of the liver. Of the cores (4, ranging between .5 and 2.0cm long and .2cm in diameter) , he says, "...taken from the hilar region in which there is appreciable fibrous tissue with large artery branches and nerves." (no wonder i was sore for so long with this bx). My interpretion is that this was not a good area to take the specimen. Given these limitations, he wrote grade 1, stage 1-2.
For the third biopsy I asked the hepo and he told me needle core either ultrasound or ct guided. He showed on the liver poster in the office where the wedges come from and said there was too much fibrous tissue in the samples. He said they needed to be about 2 cm long for a good sample. The radiologist said he uses the Ultrasound guided unless he cannot see what he needs to see in which case they wheel the bed over the CT machine and use that. It was relatively painless and the samples seem to be what the pathologist and hepatologist need.
This third biopsy - 3 1/2 years from the first, indicates grade 3-4, stage 3-4. It still has to be read by the hepatologist's pathologist. This staging was by the local pathology lab. In retrospect, I wonder if the second biopsy stage/grade was understated due to the samples.
I guess the moral to the story is all biopsies are not the same. If you are thinking about a biopsy, do consider the needle core and not the laproscopic. And if you are not considering a biopsy but have Hep C, think about getting one.
So that's my story and I'm sticking to it.
frijole
I pulled all 3 of my biopsy reports and read them and compared them. I had 2 laproscopic and 1 needle core, and have decided we need to get the needle core. For my first biopsy (2005) the GI said who do you want to do this biopsy - a radiologist or a surgeon. I thought that was a no brainer - surgeon. They come in from around the naval with a laproscopic camera and follow with the knife that cuts little wedges. These are necessarily done on the bottom side of the liver. Report showed grade 1, stage 1-2
The second biopsy (12/2007) was ordered by a hepatologist. I had already contacted the (same) surgeon for a laproscopic, but the hepo told the surgeon he wanted cores so the surgeon took wedges and cores. Looking back at the pathologist's report (the hepatologist's pathologist) he was not at all pleased with the samples. Of the wedges, he says, "there is a suggestion of periportal fibrosis, but this is difficult to evaluate because of the subcapsular nature of the biopsy specimen." -- meaning that the specimen was (.6x.6x.3) too close to the edge of the liver. Of the cores (4, ranging between .5 and 2.0cm long and .2cm in diameter) , he says, "...taken from the hilar region in which there is appreciable fibrous tissue with large artery branches and nerves." (no wonder i was sore for so long with this bx). My interpretion is that this was not a good area to take the specimen. Given these limitations, he wrote grade 1, stage 1-2.
For the third biopsy I asked the hepo and he told me needle core either ultrasound or ct guided. He showed on the liver poster in the office where the wedges come from and said there was too much fibrous tissue in the samples. He said they needed to be about 2 cm long for a good sample. The radiologist said he uses the Ultrasound guided unless he cannot see what he needs to see in which case they wheel the bed over the CT machine and use that. It was relatively painless and the samples seem to be what the pathologist and hepatologist need.
This third biopsy - 3 1/2 years from the first, indicates grade 3-4, stage 3-4. It still has to be read by the hepatologist's pathologist. This staging was by the local pathology lab. In retrospect, I wonder if the second biopsy stage/grade was understated due to the samples.
I guess the moral to the story is all biopsies are not the same. If you are thinking about a biopsy, do consider the needle core and not the laproscopic. And if you are not considering a biopsy but have Hep C, think about getting one.
So that's my story and I'm sticking to it.
frijole
pathologists seem to have some Hannibal Lecter tendencies so it may be wise to resist the endless calls for 'more liver!' . Sounds like in this case the issue may have been not so much laporoscopic vs needle as miscommunication between the surgeon and pathologist in terms of where to draw the tissue. Laparoscopic should, in principle, always yield better results since they can see exactly where they are sampling (and as a bonus you get pictures!).
However supplementing with regular FS seems a good way to track progression while awaiting treatment. No idea what the issue with echosens and the FDA is (have they even started any filing?) but the echosens web site does note approval in Mexico so that is another available option.
However supplementing with regular FS seems a good way to track progression while awaiting treatment. No idea what the issue with echosens and the FDA is (have they even started any filing?) but the echosens web site does note approval in Mexico so that is another available option.
Fibroscan is an interesting adjunct to a biopsy however the next question to expect would be "where can I get one?" and the answer to that is not very many places, including Canada, so people should be aware of that. I'm not sure that it's approved yet in the U.S. or has this been achieved now? In Canada it's generally only in major research centres, however I know of at least one regular clinic here in Ontario that offers Fibroscan now and hopefully it continues. So while some positives can be seen in also having a Fibroscan done and it's good to have choices, the reality is that they're not all that readily accessible to many people, to my understanding. Therefore, it's still biopsy as the measurement tool for most people.
Mike
"I just want you to get well and be done with this disease - so do it! "
I cannot tell you how much i appreciate you. I know that comment was from the bottom of your heart. I hope you are well and still spinning tunes.
crossroad
I read your profile and see that you started with INC 2 weeks ago. See you down the road.
frijole
will
thanks for the info - I do hope that FS are the wave of the future
"I just want you to get well and be done with this disease - so do it! "
I cannot tell you how much i appreciate you. I know that comment was from the bottom of your heart. I hope you are well and still spinning tunes.
crossroad
I read your profile and see that you started with INC 2 weeks ago. See you down the road.
frijole
will
thanks for the info - I do hope that FS are the wave of the future
Frijole, you've been through a lot. I had the ultrasound needle biopsy too. Go for the treatment.
Also, I'm glued to the computer. You guys have so much knowledge. I'm grateful they even let me start because my 1st biopsy was so bad. g 4 s 4. With the new therapy... heck the old liver has been taking care of us this long. It deserves a break from high viral loads.
Doing it. Karen
Also, I'm glued to the computer. You guys have so much knowledge. I'm grateful they even let me start because my 1st biopsy was so bad. g 4 s 4. With the new therapy... heck the old liver has been taking care of us this long. It deserves a break from high viral loads.
Doing it. Karen
frijole...it seems by the following article and other studies done .like the one Mike posted that someday it may replace bx.,however there still seems to be needed improvement in the technology.especially diagnosing overweight people and the obese.
My only reason for mentioning it in your post was. my thinking was if biopsy has approx. 25% error and someone could back could back that up with a FS(if avail) and it co-elated with the bx. then chances were that error was of a less %.
In your case ,no...it would add nothing IMO on your sound desicion to tx. now.
Again good luck and as willing has said in another thread your chances should be very good indeed.
Will
The accuracy of fibroscan score is excellent for the diagnosis of cirrhosis; it is probably the most accurate noninvasive method for the early detection of cirrhosis. It is a user-friendly technique that can be performed without any preparation in the less than five minutes in clinic or at the bedside, with immediate results and high patient acceptance, it is very likely that in future it will become the most widely used technique for assessment of liver fibrosis (10, 18). Further technological improvements are necessary for better application of this technique in obese patients and other specific populations along with efforts to improve and standardize the procedure and adequate operator training (19).
http://hepatitiscnewdrugs.blogspot.com/2011/04/fibroscan-for-assessing-liver-fibrosis.html
My only reason for mentioning it in your post was. my thinking was if biopsy has approx. 25% error and someone could back could back that up with a FS(if avail) and it co-elated with the bx. then chances were that error was of a less %.
In your case ,no...it would add nothing IMO on your sound desicion to tx. now.
Again good luck and as willing has said in another thread your chances should be very good indeed.
Will
The accuracy of fibroscan score is excellent for the diagnosis of cirrhosis; it is probably the most accurate noninvasive method for the early detection of cirrhosis. It is a user-friendly technique that can be performed without any preparation in the less than five minutes in clinic or at the bedside, with immediate results and high patient acceptance, it is very likely that in future it will become the most widely used technique for assessment of liver fibrosis (10, 18). Further technological improvements are necessary for better application of this technique in obese patients and other specific populations along with efforts to improve and standardize the procedure and adequate operator training (19).
http://hepatitiscnewdrugs.blogspot.com/2011/04/fibroscan-for-assessing-liver-fibrosis.html
I'd treat too Kathy and I wouldn't bother getting a biopsy.
I only posted that excerpt because the accuracy of LB had been mentioned and I had that article tucked away.
I just want you to get well and be done with this disease - so do it!
Mike
I only posted that excerpt because the accuracy of LB had been mentioned and I had that article tucked away.
I just want you to get well and be done with this disease - so do it!
Mike
Susan
I am not sure I agree with you that you can drop stages y doing treatment and not clearing. Everything I have read is contrary to that. Hooray for MK Andrews, but I don't think that is the norm.
as willbb and mike mention, the sampling error is possible no matter what kind of biopsy. Hector - you are right that it is best to have the biopsy done by a liver center where they see thousands of these. It all goes into a better report and the more knowledge, the better off we are for making decisions as we treat.
Mike, willbb , I wonder if the fs will ever take over the good old lb. Maybe someday but as of now my hepo says there is too great a margin of error and he still calls the lb the gold standard. Personally I dont think I will request one. My decision to treat is made and I am not sure it would add anything.
I am not sure I agree with you that you can drop stages y doing treatment and not clearing. Everything I have read is contrary to that. Hooray for MK Andrews, but I don't think that is the norm.
as willbb and mike mention, the sampling error is possible no matter what kind of biopsy. Hector - you are right that it is best to have the biopsy done by a liver center where they see thousands of these. It all goes into a better report and the more knowledge, the better off we are for making decisions as we treat.
Mike, willbb , I wonder if the fs will ever take over the good old lb. Maybe someday but as of now my hepo says there is too great a margin of error and he still calls the lb the gold standard. Personally I dont think I will request one. My decision to treat is made and I am not sure it would add anything.
I've had 5 biopsies over all these years since my diagnosis in 1994. All of them have been needle core biopsies in the right side between the ribs. I've had one fibroscan and that was done back on June 27, 2011. It pretty much went right along with the last biopsy that I'd had done in June 2010. I feel for you with your last biopsy report, but I still think that you can gain alot of improvement and even drop some stages with doing treatment again. I don't know if you remember M.K. Andrews (Miles), who used to be on Medhelp quite a bit a few years ago? He had regression in his biopsies and he still hadn't cleared either. So, it is possible to drop stages by doing treatment, even if you don't SVR. It's not like that for every person, I'll agree, but it happened for me and it happened for Miles. Susan400
Prospective Comparison of Fibroscan, King's Score and Liver Biopsy for the Assessment of Cirrhosis in Chronic Hepatitis C Infection
Posted: 02/07/2011;
"...The use of LB in chronic HCV is declining. Not only is LB associated with complications including bleeding, pain, pneumothorax, haemothorax, bile peritonitis, haemobilia, kidney and intestinal puncture and death,[5,24] but also is associated with problems of sampling error because a LB sample is only 1/50 000th of total liver volume. Regev et al. [7] showed a difference of 33% in fibrosis stage in left and right lobe LBs, while Siddique et al. [25] showed that even from biopsies taken from the same puncture site, 45% of patients could display at least one fibrosis stage of difference. Further problems occur because of intra-and inter-observer variability assessing fibrosis stage.[26] The length of LB can also be crucial in determining diagnostic accuracy. Regev showed only 65% of 15 -mm-staged liver fibrosis stage correctly, this increasing to 75% for 25mm sample. The length of LB may also be significant because fibrosis is likely to be under-staged as LB length diminishes.[9] More recently, work has been performed showing that length of LB and the number of fragments should be taken into account when evaluating the diagnostic accuracy of a test using AUROC curves.[19] This will obviously have an effect on the accuracy of LB as the gold standard and may explain in part why no test is likely to be perfect. For this reason, a sensitivity analysis on the effect on LB length above or below 15 mm was performed. This failed to demonstrate any statistical difference between the two groups in this study population. A potential advantage of FS is that it effectively samples an area of liver stiffness that is approximately of 1 cm diameter and 2 cm long, leading to a volume 100 times larger than a standard LB specimen...."
See: http://www.medscape.com/viewarticle/735545_4
Posted: 02/07/2011;
"...The use of LB in chronic HCV is declining. Not only is LB associated with complications including bleeding, pain, pneumothorax, haemothorax, bile peritonitis, haemobilia, kidney and intestinal puncture and death,[5,24] but also is associated with problems of sampling error because a LB sample is only 1/50 000th of total liver volume. Regev et al. [7] showed a difference of 33% in fibrosis stage in left and right lobe LBs, while Siddique et al. [25] showed that even from biopsies taken from the same puncture site, 45% of patients could display at least one fibrosis stage of difference. Further problems occur because of intra-and inter-observer variability assessing fibrosis stage.[26] The length of LB can also be crucial in determining diagnostic accuracy. Regev showed only 65% of 15 -mm-staged liver fibrosis stage correctly, this increasing to 75% for 25mm sample. The length of LB may also be significant because fibrosis is likely to be under-staged as LB length diminishes.[9] More recently, work has been performed showing that length of LB and the number of fragments should be taken into account when evaluating the diagnostic accuracy of a test using AUROC curves.[19] This will obviously have an effect on the accuracy of LB as the gold standard and may explain in part why no test is likely to be perfect. For this reason, a sensitivity analysis on the effect on LB length above or below 15 mm was performed. This failed to demonstrate any statistical difference between the two groups in this study population. A potential advantage of FS is that it effectively samples an area of liver stiffness that is approximately of 1 cm diameter and 2 cm long, leading to a volume 100 times larger than a standard LB specimen...."
See: http://www.medscape.com/viewarticle/735545_4
frijole-
One more reason to have knowledgeable and experienced doctors and technical staff to ascertain the correct diagnosis. When we recommend a hepatologist and they supporting personnel at a liver transplant center, we do so because these are medical professionals that perform testing, evaluation and diagnosis of liver disease on a daily basis and know how to use proper protocols and procedures in order to produce the most accurate diagnoses possible given the current state of technology. I think we hear enough instances of mis-diagnoses, incomplete diagnosis, and improper treatment on this forum to know that the best chances of curing hepatitis C is when qualified medical personnel are involved in supporting patients with chronic hepatitis C.
Cheers!
Hector
One more reason to have knowledgeable and experienced doctors and technical staff to ascertain the correct diagnosis. When we recommend a hepatologist and they supporting personnel at a liver transplant center, we do so because these are medical professionals that perform testing, evaluation and diagnosis of liver disease on a daily basis and know how to use proper protocols and procedures in order to produce the most accurate diagnoses possible given the current state of technology. I think we hear enough instances of mis-diagnoses, incomplete diagnosis, and improper treatment on this forum to know that the best chances of curing hepatitis C is when qualified medical personnel are involved in supporting patients with chronic hepatitis C.
Cheers!
Hector
Just to add to what Frijole has posted as there is approx. a 25% sampling error in biopsy possibly a good idea to ask if a fibroscan is avail in addition to add one more marker to the result.
Fwiw... Both my bx. were needle core and both corelated exactly with FS finding.
Thx Frijlole...
Will
Fwiw... Both my bx. were needle core and both corelated exactly with FS finding.
Thx Frijlole...
Will
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