back to back biopsys??

Question

My doc says we are probably going to do another biopsy next Tuesday...I had one on Oct. 8th And was dx with 1st stage cirrhosis...biopsy read as followed..

An adequate liver biopsy is obtained for examination. Sections show moderate portal inflammation with lymphoid aggregates, interface hepatitis, and lobular activity. The inflammatory infiltrate consist primarily of lymphocytes. There is mild to moderate macro and microvesicular steatosis. there is septal fibrosis with some architectural distortion and a focal area showing bridging fibrosis with nodular regeneration, that is best seen with trichrome and reticulin stain.PAS stain is negative for alpha-1-antitrypsin globules. An iron stain shows 1+ iron with hepatocytes. NO viral inclusions, granulomas, dysplasia or malignancy are seen.....

At the time of this bx my ALT was 567...AST 297...GGT 144 & my VL was 8 million

I was dx with hep c in 1995...biopsy then  showed no damage..ALT 50 VL 2 million..." no treatment necessary at this time " 
This was done by a different dr, different location..

Okay..since my bx 2 months ago my #s have changed alot...
My ALT has gone from 567..398..192 then up to 807 then 1 week later 942 (last Wednesday)

MY GGT has gone from 87...202...238 (last wed.)

What could cause a change in bx results in a 2 month timeframe?
I understand you can't tell me exactly what is going on but maybe what you think he is looking for?? Is there something so aggresive that could cause a change that fast?

I am 43 male type 1a non smoker..clean and sober since 1987..
Thanks..God Bless

willing · Answer

Hi Dheana, the Ishak scale uses a more fine grained breakdown of fibrosis levels: see table 1 of the following paper for a description of the labels. Stage 2 on the Ishak scale would be considered mild scarring : the decision to treat is entirely at the discretion of the patient. If you do SVR, you can expect slow but gradual reversal of that fibrosis, reduced risk of HCC and other goodies. Hang in there Dheana, you're so close to the end! And give yourself PLENTY of time to recover.

GI.PA · Answer

Typically successfully treated Hep C will result in improvement in the liver biopsy.  Fibrosis can reverse (maybe not to normal liver tissue but pretty good).  When proving the treatment in studies they would biopsy pretreatment and post treatment and are universally able to prove biopsy improvement with SVR or even viral supression (the basis of the HALT-C trial now..www.haltctrial.com).

Nowdays we do not usually re-biopsy at the end of treatment.  Usually ALT's have normalized and we take that as a very good sign.  The only way I would re-biopsy is if the numbers remained significantly elevated and advanced liver disease was not in the first biopsy..I would want to know exactly what else could be going on there!

GI.PA

willing · Answer

Hi - yeah, it is a small world, and it's always reassuring to see your Dr's name on a research pub. It'd be good to talk to your GI about the relative risks of guided/unguided bx. Clearly the guided seems preferable but unless you're prepared to switch Drs you'll have to stick with their accustomed practice. You might also want to talk about size (length and diameter) of the tissue sample. There's been a move to smaller gauge needles and shorter samples and recent studies have shown this introduces more sampling error (see an editorial and article in this month's issue of Hepatology. A sample at least 2.0 cm long and 1.4mm across seems to provide more reliable information and that is longer than most bx's (my last one was only 1.5 cm for example). Also, from what you wrote ,I don't see any reason to delay tx : as a stage 4 you want to start getting your fibrosis under control as soon as practical. Best wishes.

dheana · Answer

My doctor uses other scale from evaluating fibrosis (Isack???) which has 6 stages of fibrosis.
I'm close to the end of treatment, week 47 with undetectable results at week 12 and 24. My ALT is now 20 (I started somewhere near 160).
My doctor told me that I have chances for a SVR, in this situation, what will happen with the fibrosis? Is there any chance to cure it?

DebbieDo · Answer

Thanks for you input...I have been lurking here for about 6 months now......some of this stuff is hard to understand.  I'm a 1b w/mild fibrous.....VL 5.9 which now i have learned is LOW...I'm ready for fight this > dragon......I know alot of people on this forum are really sick.  My heart and love goes out to them. GOD BLESS everyone here......I will look forward to all the support i can get once i start TX.. I live alone, so, this makes things scarey for me...with all the sides.... I think positive all the time........thanks again

GI.PA · Answer

This is middle of the road.  Your inflammation score is 8 our of 18.  Your fibrosis is 2 of 4 (mild to moderate).  Treatment should probably be considered or, at minimum, a repeat biopsy in 3 years.

GI.PA

newtex · Answer

Hi..and welcome from a fellow newbie ( new to treatment )...let me echo that having a low VL is a GOOD thing...I haven't even started tx (treatment) yet but I have become a regular on this forum.....Someone a couple of weeks ago said " knowledge is power " Not only has this been a great place for mental support but reading here every day I learn about my Disease ( AKA THE DRAGON )...I like knowing and understanding others experiences with hep c and it's tx....you will see lots of web sites posted also...my 2 cents is read alot and ask a few questions...Good luck and God Bless

BobK · Answer

Quite the opposite!  You have one more item in your favor as far as achieving SVR.   Low viral load is a good thing!

regards,
BobK

GI.PA · Answer

This is completely operator dependent.  Your GI or Radiologist (whoever is doing it) will have a preference.  Or the facility at which you have it done will do them a certain way.  If they are very comfortable with the anatomy (from many previous CT's or ultrasounds, they may even do it without any guidance).

This is a doctor call...there is no right or wrong way.

GI.PA

DebbieDo · Answer

So, what are you saying.......that i have a low VL and i might not even respond to TX......i plan to start Dec 29....Pegasys and Riba?? I dont understand alot of this stuff......

dheana · Answer

My bx results are 
inflamation 8/18 and fibrosis 2/6. How bad is this?

newtex · Answer

After reading the link " REVIEW " that you posted, I scrolled through the references and found my docs name....# 25 FB Hollinger...SOoo, just like the song says...It's a small world after all!Good night

newtex · Answer

Thanks for your insights...Knowing what might be going on is better than being totally in the dark....two follow-up questions...Do I take it you both agree with not starting tx. until we get more answers....And Do you agree with what I have read on this forum several times, that I should ask for a CT guided biopsy...The one in Oct. was not CT guided and It wasn't that bad...I am 100% confident in my Dr.......again just wondering what your thoughts are...CT guided vs not? God Bless

willing · Answer

hey, don't feel left out: 5.9 is you VL score on a log scale. To go to standard scale calculate 10^5.9=794,000. Anything below 800,000 IU is considered a "low" baseline VL as far as likelihood of tx response.

DebbieDo · Answer

Everyone posts their VL as in the millions......what is 5.9?  This is what my doctor told me mine was.......

willing · Answer

Hi - "no damage" to "1st stage cirrhosis" in 8 years seems an unusually quick progression. Also, an increase in VL from 2 to 8 million is outside the three-fold increase/decrease fluctuation associated with a chronic infection "steady state". There's nothing in the comments from the Oct. bx to show there was any issue with obtaining an adequate sample so my guess is that your GI is not so much 2nd-guessing the Oct. results as looking for more data that would indicate accelerated scarring. Rate of progression of HCV-induced fibrosis is affected by many factors, including fatty-liver and increased iron stores, and some of these can be addressed by therapy (see "host factors" in the following review of fibrosis progression. As Erin suggested, there may be factors unrelated to HCV, or your GI might be concerned about accelerated HCV-induced scarring. Best wishes.

GI.PA · Answer

This is a puzzle...why would your numbers be fluctuating into, and above the 500 mark.  Could this be the Hep C? possibibly but this level of elevation is usually more consistant with a more "acute" process verses the low grade "chronic" stuff with Hep C.  By doing another biopsy,they will be looking for clues as to what is causing the acute nature of your numbers.  They may be taking a larger sample which can be sent off to Mayo(or another large hospital) for more in-depth testing on iron, copper levels and second opinions.  They may do more indepth staining looking for other types of cells/patterns in the biopsy.  

This should be combined with a thourough set of lab inquiries into coexisting Hep A or B, autoimmue marker, thyroid studies and even consideration for a disease caused celiac sprue (unlikely).  Iron and copper studies can help rule/in/out trouble with iron or copper pathways.

In the end, we may not know what raised the numbers.  If they return to baseline or the biopsy gives no more information that already gained, we may need to assume Hep C and go from there.

GI.PA

newtex · Answer

The Question on this thread was for your comments...or any one else with any thoughts or comments...Thanks again and God Bless

back to back biopsys??

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